UNIVERSITY  OF  CALIFORNIA 
AT    LOS  ANGELES 


PHYSICAL  RECONSTRUCTION 
AND  ORTHOPEDICS 


4  4  7  3     9 


PHYSICAL  RECONSTRUCTION 
AND  ORTHOPEDICS 


By 
HARRY  EATON  STEWART,  M.D. 

CAPTAIN  MEDICAL  CORPS,  U.S.  ARMY,  DIVISION  OF  ORTHOPEDICS ;  ASSISTANT  DIREC- 
TOR, SECTION  OF  PHYSIOTHERAPY,  SURGEON  GENERAl'sOFFICE;  INSTRUCTOR 
IN  MEDICAL  AND  ORTHOPEDIC  GYMNASTICS  AND  MASSAGE,   NEW  HAVEN 
NORMAL  SCHOOL  OF  gymnastics;  ATTENDING  SURGEON,  NEW  HAVEN 
ORTHOPEDIC  dispensary;  FORMERLY  INSTRUCTOR  IN  CORRECTIVE 
GYMNASTICS,  TEACHERS     COLLEGE,    COLUMBIA    UNIVERSITY. 


Authorized  for  Publication  by  the 
Surgeon  General  of  the  U.  S.  Army 


67  ORIGINAL  ILLUSTRATIONS 
AND  2  DIAGRAMS     ^ 


M 

1 

Ini 

i 

1^ 

lOEHK 

1 

NEW  YORK 

PAUL  B.  HOEBER 

1920 


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Copyright,  1920, 
Bt  PAUL  B.  HOEBER 


Published  Janvary,  19S0 


'*<■*<*     »<.       '*ti*i 


Printed  in  the  United  States  of  Ameriea 


7CS' 


PKEFACE 

Physical  reconstruction  is  the  watchword  of  the  hour — 
and  yet  the  picture  brought  to  mind  by  this  phrase  is  but 
a  small  part  of  a  greater  problem,  the  physical  recon- 
struction of  the  race.  That  there  is  need  for  such  recon- 
struction among  us  is  evident  from  any  study  of  the  re- 
jection from  service  for  physical  disability  which  the 
draft  examinations  brought  forth.  We  have  become  a 
city-dwelling  nation,  and  are  subject  to  the  innumerable 
deleterious  influences  which  follow  in  the  wake  of  city  life 
and  intense  industrial  competition.  The  meager  begin- 
nings of  playground  and  physical  education  appropria- 
tions and  infant  welfare  movements  have  as  yet  in  no 
way  compensated  the  child  for  his  rapid  loss  of  outdoor 
life  and  freedom.  The  physician  must  be  deeply  con- 
cerned with  every  effort  to  improve  child  hygiene.  He 
is  specifically  concerned  with  the  problem  of  prevention 
and  cure  of  remedial  physical  defects.  In  this  book  con- 
crete directions  are  given  regarding  -spinal  curvature, 
congenital  defects,  rickets  and  other  orthopedic  condi- 
tions. The  question  of  competitive  athletics  and  its  rela- 
tion to  health  in  youth  of  both  boys  and  girls  is  considered 
and  certain  definite  rules  for  safeguards  are  laid  down. 

In  the  reconstruction  of  the  wounded  soldier,  in  which 
we  and  our  allies  are  now  engaged,  much  that  is  new  and 
of  great  value  has  been  learned.    The  new  orthopedic 


vi  PREFACE 

principles,  appliances,  and  methods  of  treatment  which 
have  been  evolved  have  been  thoroughly  tried  out  under 
exceptional  conditions  as  regards  amount  of  material, 
length  of  observation,  and  unlimited  resources. 

The  application  of  the  successful  methods  evolved  in 
the  treatment  of  war  injuries  to  the  treatment  of  indus- 
trial accidents  is  of  the  utmost  importance  to  the  general 
surgeon.  Physiotherapy  and  vocational  therapy  have, 
by  proper  application  and  coordination,  achieved  such 
wonderful  results  that  it  is  inconceivable  that  they  can 
have  other  than  a  very  prominent  place  in  the  general 
hospital  in  the  future.  Every  physician  and  surgeon 
should  be  familiar  with  the  indications  for  the  various 
types  of  treatment,  and  their  effects  on  the  local  and 
general  condition  of  the  patient,  his  morale,  and  his  re- 
turn to  his  former  or  new  occupation.  When  one  consid- 
ers that  the  number  of  our  wounded  was  approximately 
two  hundred  thousand,  the  importance  of  the  viewpoint 
just  mentioned  is  seen  when  we  remember  that  we  have  in 
this  country  about  seven  hundred  thousand  industrial 
accidents  yearly. 

The  author's  experience  in  teaching  and  supervisin.g 
reconstruction  aides  in  physiotherapy  has  convinced  him 
that  a  condensed  manual,  giving  the  directions  for  the 
various  types  of  treatment  as  well  as  the  theoretical  con- 
siderations, would  be  of  great  assistance  to  them  in  the 
work  in  which  they  are  now  engaged.  Since  vocational 
reconstruction  is  being  so  largely  applied  for  definite 
therapeutic  indications,  it  is  of  the  greatest  importance 
that  the  workers  in  this  corps  understand  the  viewpoint 


PREFACE  vii 

and  treatment  given  in  physiotherapy,  which  leads  up  to 
their  work.  The  theory  and  treatment  of  congenital  and 
functional  defects  other  than  those  following  war  injuries 
should  be  useful  to  aides  who  plan  to  continue  the  same 
type  of  work  in  civil  life. 

In  the  teaching  of  normal-school  students  of  physical 
education  it  has  also  been  evident  that  they  need,  for 
their  work  in  orthopedic  and  medical  gynmastics,  definite 
exercise  programs  for  such  conditions  as  faulty  posture, 
spinal  curvature,  infantile  paralysis,  flat  foot,  etc. 

It  has  been  the  author's  object  to  present  in  condensed 
form  the  main  principles  of  orthopedics  in  the  treatment 
of  the  defects  of  childhood,  war  injuries,  and  industrial 
accidents,  laying  stress  upon  the  treatment  by  massage, 
exercise,  and  other  types  of  physiotherapy.  It  should, 
therefore,  be  of  value  to  the  physician,  reconstruction 
aide,  physical  director,  and  orthopedic  assistant,  not  only 
in  their  better  understanding  of  the  work,  but  in  empha- 
sizing the  vital  importance  of  this  so  long  neglected  field. 

The  author  wishes  to  acknowledge  the  valuable  aid 
given  him  by  Miss  Helen  S.  Willard,  B.A.,  his  chief 
Eeconstruction  Aide  in  Physiotherapy,  and  Captain  G. 
W.  Ramaker,  Vocational  Therapy  Officer  of  the  U.  S.  A. 
Base  Hospital,  Camp  Meade,  Maryland,  in  the  collection 
of  data  for  this  book. 

H.  E.  S. 

New  Haven,  Conn. 
Sept.  1,  1919 


CONTENTS 
PART  I 

PHYSICAL  RECONSTRUCTION 

CHAFTBR  PAOB 

I    Exercise 1 

Relation  of  Bodily  Health  to  Muscular  Health.  Nerve 
Strain  of  Modem  Work.  Necessity  for  Physical  Train- 
ing in  Youth.  Athletic  Problems.  Heart  Strain. 
Safeguards  for  Boys  and  Girls  in  Athletics.  Proper 
Exercise  for  Various  Ages.  Therapeutic  Exercises. 
Physiology  and  Pathology  of  Muscle  Tissue.  Exercises 
for  Stiff  Joints.    Setting-up  Exercise. 

II    Baking. — Hydrotherapy. — Electrotherapy    .     .       27 

Physiolo^cal  Changes  by  Baking.  Passive  Hyperemia, 
Hydrotherapy — Definition,  History.  Properties  of 
Water.  Physiological  Effect  on  the  Various  Tissues  and 
on  Body  Temperature.  Technique  of  the  Various  Baths. 
Electrotherapy — Types  of  Ciirrent,  Uses.  Ionic  Medica- 
tion.   Alpine  Sun  Lamp. 

III  Massage 46 

Definition.  History.  Tsrpes  of  Movement.  General  Con- 
siderations. Effect  on  Different  Tissues.  Mechanics  of 
the  Cardinal  Movements.  Therapeutic  Uses  and  Con- 
traindications.   Treatment  of  Limb  Stumps. 

IV  Vocational  Therapy 7ft 

Objects — Therapeutic,  Economic,  Occupational  Interest, 
Morale.  Co-operation  with  Physiotherapy,  with  Federal 
Board.  Types — Bedside,  Shop,  Classroom,  Field. 
Scope — Application  in  General  Hospitals,  Simple  Equip- 
ment,  Relation  to   Industrial  Accidents. 


X  CONTENTS 

PART  II 
ORTHOPEDICS 

CHAPTER  PAOB 

V    Congenital  Defects 91 

\^lub  Foot — Types,  Treatment.    Hip  Dislocation.    Hibb's 
"Table.    Rickets — Cause,  Diagnosis,  Treatment.    Coxa 
Vara — Pathology,    Treatment.         Spastic    Paralysis — 
Causes,  Treatment. 

VI  Infantile  Paralysis 97 

Pathology.  Treatment  in  Active  Stage.  After-treatment. 
Exercises  for  Paralyzed  Arm  and  Leg. 

VII    The  Spine — Diseases  and  Injuries 106 

Anatomy.  Tuberculosis — Diagnosis,  Symptoms,  Treat- 
ment. Traumatic  Injuries,  Strain  and  Sprain.  Sacro- 
iliac Strapping.  Treatment  of  Bruises.  Fractures  and 
Dislocations  —  Diagnosis,  Treatment.  Penetrating 
Wounds. 

VIII    Curvature  of  the  Spine HI 

Kyphosis — Tjrpes,  Causes,  Symptoms,  Treatment, 
Program  of  Exercises.  Lordosis — Occurrence,  Causes, 
Sequelae,  Program  of  Exercises.  Scoliosis — Pathology, 
Rotation,  Occurrence,  Classifications,  Causes,  Treat- 
ment.   Exercise  Programs  for  the  Various  Types. 

IX    Joint  Injuries  and  Arthritis 135 

General  Anatomy.  Traiunatic  Lesions.  Strain  and 
Sprain — Treatment.  Arthritis.  Toxic  Arthritis.  Ar- 
thritis Deformans,  or  Rheumatoid  Arthritis—  Diagnosis, 
Treatment.  Acute  Rheumatic  Arthritis.  Tuberculous 
Arthritis — Diagnosis,  Treatment.  Gonorrheal  Ar- 
thritis— Diagnosis,  Treatment.  Syphilitic  Arthritis — 
Diagnosis,  Treatment. 

X    Diseases  of  Bones 146 

Periostitis — Pathology,  Diagnosis,  Treatment.  Osteitis. 
OsteomyeUtis — Diagnosis,  Treatment.  Osteomalacia — 
Diagnosis,  Treatment. 


CONTENTS  xi 

CHAPTEB  PAGB 

XI  Fractures    and   Dislocations. — The    Upper    Ex- 

tremity        152 

The  Clavicle.  Sternoclavicular  Dislocations.  Fractures. 
Acromioclavicular  Dislocations.  The  Scapula.  Fractures. 
Shoulder  Joint,  Surgical  Anatomy.  Types  of  Dis- 
location. Fractures  of  the  Humerus.  Anatomica.'  Neck. 
Shaft.  Supracondyloid.  Epicondyloid.  Epitrochlear. 
Fractures.  Involving  the  Elbow.  Types.  Olecranon 
Dislocations  of  tho  Elbow.  Types.  Myositis  Ossificans, 
Traumatica.  Dislocations  of  the  Radial  Head.  Ankylosis 
of  the  Elbow.  Fracture  of  the  Head  of  the  Radius. 
Fractures  of  the  Shaft.  Fractures  of  the  Radius  and 
Ulna.  The  Wrist.  CoUes  Fracture,  Dislocations.  The 
Hand — Fractures,  Dislocations. 

XII  Fractures  and  Dislocations  (Continued).     The 

Lower  Extremity 183 

The  Pelvis.  Types  of  Fracture.  Dislocation  of  the  Sym- 
physis. Dislocations  of  the  Hip  Joint.  Fractures  of  the 
Femur.  Upper  End.  Shaft.  Lower  End.  Fractures  and 
Dislocations  of  the  Patella.  Dislocation  of  the  Knee. 
Fracture  and  Dislocation  of  the  Semilunar  Cartilages. 
Rupture  of  the  Crucial  Ligament.  Fractures  of  the 
Upper  End  of  the  Tibia  and  Fibula.  Fractures  of  the 
Shaft.  Lower  End.  Pott's  Fracture.  Dislocations  of  the 
Ankle.   Fractures  of  the  Metatarsus. 


XIII    Foot  Strain  .     y. 205 


y 


The  Main  Arch.  Types  of  Flat  Foot — Causes,  Diagnosis, 
Treatment,  Strapping,  Plates,  Exercise,  Programs.  The 
Anterior  Arch.  Metatarsalgia— Causes,  Diagnosis,  Exer- 
cises. Foot  Ailments  in  the  Army.  Foot  Strain- 
Literature,  Military  Viewpoint,  Classification,  Anatomy, 
Methods  of  Examination.  Diagnosis  and  Treatment  of 
Weak  Foot.  Flaccid  Flat  Foot.  Rigid  Foot.  Acute  and 
Chronic  Foot  Strain.  Hammer  Toe.  Corrective  Shoe 
Appliances.  Minor  Foot  Ailments.  Synovitis.  Blisters. 
Abrasions.  Tissues.  Overriding  Toes.  Corns.  Callosi- 
ties. Warts.  Sweating  Feet.  Chilblains.  Trench  Foot. 
Shoe  Fitting.    Prescriptions. 


xii  CONTENTS 

CHAFTKR  PAOB 

XIV    Braces  and  Casts 229 

Braces  for  Arch,  Club  Feet,  Knee,  Bowleg,  Knock  Knee. 
Infantile  Leg.  Spine.  Casta.  Care  and  Preparation  of 
Plaster  Technique. 

Glossart    .... 235 

Index 237 


LIST  OF  ILLUSTRATIONS 

no.  PAGE 

1  Entire  Scapula,  Except  Part  of  Acromion,  Missing  .     .  5 

2  Gain  from  Complete  Disability  in  Six  Weeks  of  Physio- 

therapy   5 

3  Severe  Shrapnel  Wound  of  Left  Shoulder  with  Com- 

pound Comminuted  Fracture  of  6th  and  7th  Ribs     .  11 

4  Slanting  Ladder,  Use  of  Body  Weight  to  Secure  Passive 

Flexion  of  Stiff  Knee  Joint 15 

5  Suspension  Used  to  Stretch  Adhesive  Bands  in  Right 

Elbow 15 

6  Chipping  of  Humeral  Head  and  Extensive  Wound  of 

Shoulder 21 

7  Abduction  Assisted  Largely  by  Scapular  Rotation  Well 

Controlled 21 

8  Hyi)erextension  Limited  by  Scar  Tissue  and  Adhesions  .  21 

9  Muscle  Contraction  Test  for  Nerve  Injury.    Faradic 

Battery  and  Generator 25 

10  Baking.    Electric  Light  Bath  of  Knee     .....  26 

11  Diathermy.      Electrical   Heat   Penetration   for   Deep 

Hyperaemia 26 

11a  Multiplex  Sinusoidal  Machine 31 

lib  High  Frequency  Machine 31 

lie  Alpine  Sun  Lamp,  Ultra  Violet  Ray 32 

12  Electro-Motor  Points,  Upper  Extremity 37 

13  Electro-Motor  Points,  Lower  Extremity 38 

14  Electro-Motor  Points,  Trunk 41 

15  Massage.    Effleurage  or  Stroking  of  Forearm     ...  47 

16  Massage.    Petrissage  or  Kneading  of  Calf    ....  47 

17  Passive  Stretching  of  a  Flexion  Contracture  at  the  Elbow  61 

18  Massage.    Friction  Here  Used  to  Loosen  Scar  Tissue  .  51 

19  Massage.    Tapotement  or  Hacking  of  Muscle    ...  55 

xiii 


xiv  LIST  OF  ILLUSTRATIONS 

FIG.  PAGE 

20  Posterior  Half  Cast  to  Prevent  Foot  Drop    ....  55 

21  High  Explosive  Wound  of  Left  Hand 59 

22  Loss  of  3d  and  4th  Metacarpals 59 

23  Basket-Making 77 

24  Telegraphy 77 

25  Clay  Modeling 78 

26  Chair  Caning 78 

27  Wood  Toy  Making 78 

28  Teaching  the  Beginnings  of  Mechanical  Principles  .     .  83 

29  Adjustable  Foot  Appliances 87 

30  Musical  Knowledge  Reapplied  to  an  Instrument  the 

Man's  Disability  Will  Allow  Him  to  Play  ....  88 

31  Automobile  Repair  Shop 88 

32  Woodworking 88 

33  Carriage  Which  Reduces  Friction  and  Allows  on  a 
Smooth  Surface  a  Wide  Range  of  Movement  with  Slight 

Effort 95 

34  Wire  Cockup  Splint  for  Wrist  Drop,  Light  in  Weight, 

and  Requires  no  Bandaging 95 

35  Self -Correction  for  Right  Dorsal  Left  Lumbar  Scoliosis  .  125 

36  Spring  Sitting-Position  in  Right  Dorsal  Left  Lumbar 

Scoliosis 125 

37  Osteomyelitis  of  Lower  End  of  Tibia  and  Osteo- Arthritis 

of  Ankle  Joint 147 

38  External  Condyle  of  Femur  Shot  Away.    Osteomyelitis 

and  Ankylosis 147 

39  Cabot  Posterior  Leg  Splint 155 

40  Airplane  Splint  with  Elbow  Joint 155 

41  Abduction  Splint  for  Shoulder 159 

42  Humeral  Extension  Splint        159 

43  Comminuted  Gunshot  Fracture  of  Glenoid  and  Humerus 

at  Surgical  Neck,  with  Large  Amount  of  Bone  De- 
struction       163 

44  Humeral  Neck  and  Head  Fractured,  Beginning  Bony 

Union.    Shrapnel  in  the  Head 163 

45  Extensive  Shrapnel  Wound  of  Right  Arm  with  Com- 

pound Conuninuted  Fracture  of  Humerus  .     .     .     •  171 


LIST  OF  ILLUSTRATIONS 


XV 


FIQ.  PAQB 

46  Machine-Gun  Bullet  Through  Condyles  of  the  Left 

Humerus 171 

47  Old  Infected  Gunshot  Wound  of  Upper  End  of  Right 

Radius  and  Ulna  Involving  Elbow  Joint     ....     171 

48  \  Compound  Comminuted  Fracture,  Oblique  of  Radius 

49  J      and  Transverse  of  Ulna  with  Over-Riding  of  Frag- 

ments     175 

50  Loss  of  Bone  in  the  2d  and  3d  Metacarpals  with  New 

Joint  Formation 175 

51  Loss  of  Portion  of  2d  and  3d  Metacarpal      ....     175 

52  Extension  Applied  to  Fracture  of  Both  Bones  of  the 

Forearm 179 

53  Bradford  Frame  with  Extension  Applied  to  Leg  for 

Fracture  of  Femur  with  Shortening 179 

54  Caliper  Walking  Splint        189 

55  High  Explosive  Shell  Wound  of  the  Hip,  Sustained  July 

14,  1918 189 

56  Fracture  of  Tibia,  Compound  Comminuted,  with  Large 

Loss  of  Bone  Substance 199 

57  Fall  fom  Horse  Causing  Fracture  Through  Head  of 

Astragalus 199 

58  Compound  Comminuted  Fracture  of  Tibia  and  Fibula  .  199 

59  Exercise  11.    Walking  Forward  on  Outer  Edge  .     .     .  207 

60  Exercise  III.    Rising  on  Toes,  Toeing  In      ....  207 

61  Exercise  IV.    Walking  Forward  on  Outer  Edge,  Toeing 

In 207 

62  Exercise  V.    Ground  Gripper  Walk 207 

63  The  Hammock  Arch  Plate 213 

64  The  Hammock  Arch  Applied 213 


PHYSICAL  RECONSTRUCTION 
AND  ORTHOPEDICS 

PART  I 
PHYSICAL  RECONSTRUCTION 

Chapter  I 
EXERCISE 

The  health  of  the  body  is,  in  the  last  analysis,  abso- 
lutely dependent  upon  the  health  and  tone  of  the  muscular 
system.  The  condition  of  the  heart  muscle  and  the  non- 
striated  fibers  of  the  blood  vessels  and  gastrointestinal 
tract,  are  profoundly  influenced  by  the  tone  of  the  skeletal 
muscles.  Many  glands  are  stimulated  both  directly  and 
indirectly  as  a  result  of  proper  muscular  activity.  These 
statements  are  obvious,  almost  trite,  and  yet  they  are 
constantly  overlooked.  The  physician  often  treats  first 
by  drugs,  then  with  attention  to  diet  and  sleep,  and  lastly, 
if  at  all,  by  exercise. 

In  modem  business  and  industrial  life  the  premium  is 
placed  upon  nervous  activity  and  very  fine  muscular  co- 
ordination. This  type  of  work  is  exhausting  without  any 
corresponding  upbuilding  of  vigor.  Physical  work  in- 
volving larger  groups  of  muscles,  while  equally  tiring, 


2  PHYSICAL  EECONSTRUCTION 

tends  to  build  up  both  the  muscular  structure  and  the 
general  health.  Years  ago  even  the  skilled  artisan  used 
to  move  about  the  plant  selecting  his  materials,  perform- 
ing quite  varied  operations  upon  them,  and  perhaps  car- 
ried the  finished  product  to  the  shipping  room.  There- 
fore he  was  compelled  to  take  a  certain  amount  of  general 
exercise.  Modem  efficiency  has  ruled  that  cheap  labor 
shall  bring  in  these  materials,  perform  the  easier  opera- 
tions, and  remove  the  finished  product,  while  the  arti- 
san's entire  time  is  occupied  in  repeating,  hundreds  of 
times  daily,  some  one  or  two  specialized  movements, 
which  usually  require  prolonged,  acute  attention  and 
delicate  coordination.  Thus  only  certain  small  muscle 
groups  are  apt  to  be  used. 

The  same  tendency  is  seen  in  modem  business  and 
professional  life,  where  present  appliances  make  it  pos- 
sible to  conduct  a  whole  day's  business  from  the  office 
chair. 

The  many  occupations  which  require  standing  for 
hours  subject  those  muscles  which  maintain  the  upright 
posture  to  strain,  rather  than  exercise.  The  work  of 
the  heart,  unassisted  by  alternating  muscular  compres- 
sion and  relaxation  applied  to  the  veins,  is  greatly  in- 
creased, and  the  muscles  and  ligaments  of  the  foot  are 
subject  to  a  distinct  strain.  It  must  be  clear,  then,  since 
most  occupations  resemble  more  or  less  one  or  the  other 
of  the  three  types  of  occupations  mentioned,  that  the 
average  person  under  modern  conditions  does  not  have 
sufficient  exercise  for  the  maintenance  of  the  best  effi- 
ciency. That  women,  as  a  class,  with  the  added  handicap 


EXERCISE  3 

of  dress  and  social  restrictions,  take  far  too  little  exercise 
every  one  will  recognize. 

There  is  no  escape  from  the  tendency  of  modem  life 
further  and  further  to  restrict  normal  exercise  and  in- 
crease the  strain  of  professional  and  industrial  life.  I 
take  it  to  be  of  the  utmost  importance  that  we  should 
see  to  it  that  every  child  and  youth  be  given  the  oppor- 
tunity to  lay  by  a  surplus  in  his  bank  account  of  health, 
for  these  certain  and  severe  strains  which  modem  life 
makes  it  impossible  for  him  to  avoid.  Since  we  have 
become  a  city-dwelling  nation,  with  extremely  limited 
play  space,  the  youth  is  not  so  apt  to  be  endowed  with  a 
vigorous  muscular  system  at  the  beginning  of  his  life 
work  as  were  his  father  and  grandfather.  Until  we  have 
multiplied  our  playground,  recreational  center,  and 
school  gymnasium  appropriations  many  times  over,  wo 
shall  suffer  as  a  nation  from  this  lack  of  muscular  vigor. 

That  every  child  should  have  a  thorough  physical 
training  is  recognized  by  every  physician.  There  are, 
however,  problems  closely  associated  with  modem  ath- 
letics which  relate  to  possible  overstrain  of  heart  and 
disturbed  blood  pressure,  which  are  not  universally  un- 
derstood. During  my  experience  in  the  physical  educa- 
tion of  both  girls  and  boys,  I  was  struck  with  the  lack 
of  definite  knowledge  in  the  profession  of  the  results  of 
vigorous  athletic  training  on  the  heart  and  blood  pres- 
sure. 

The  heart  becomes  stronger,  the  cardiovascular  ad- 
justment more  perfect,  and  the  blood  pressure  is  not 
raised,  by  athletic  training.    Safeguards  that  the  physi- 


4  PHYSICAL  RECONSTRUCTION 

cian  should  insist  "upon  in  all  athletic  sports  in  both  boys 
and  girls  are,  first,  preliminary  medical  examination; 
second,  constant  trained  supervision;  third,  play  only 
when  in  perfect  health.  I  want  to  emphasize  the  fact  that 
the  delicate  child  can  be  built  up,  and  should  be  encour- 
aged to  exercise  when  carefully  watched;  that  the  heart 
is  a  muscle,  and  as  such  can  be  increased  in  both  size 
and  strength  when  carefully  kept  from  strain. 

The  physician's  advice  is  often  sought  by  parents  in 
regard  to  the  proper  amount  of  physical  training  that 
should  be  taken  by  the  normal  child.  Such  advice  can 
hardly  be  given  without  a  knowledge  of  the  circumstances 
surrounding  the  exercise,  which  may  have  a  marked  effect 
upon  the  benefits  derived.  The  number  and  length  of  the 
periods  per  week,  their  time  relation  to  meals  and  fa- 
tigue, temperature,  ventilation,  apparatus  used,  and  the 
way  the  schedule  is  graded,  all  are  important. 

Nearly  every  normal  boy  goes  in  for  athletics.  His 
enthusiasm,  and  that  of  the  coach  who  must  produce  a 
winning  team,  make  it  very  easy  to  overstep  the  limits  of 
safety.  We  must  remember  that  the  boy,  as  a  rule,  id 
carrying  a  heavy  burden  of  growth,  development,  study, 
and  extra-curriculum  activity. 

It  must  be  constantly  kept  in  mind  that  the  growth 
of  the  heart  and  larger  blood  vessels  is  from  one  to  two 
years  behind  the  rest  of  the  body,  during  adolescence. 
For  this  reason  heart  strain  is  more  common  than  gen- 
erally realized.  Such  games  as  basketball,  football,  and 
hockey  should  be  broken  up  by  frequent  rest  periods.  I 
believe  no  secondary-school  boy  should  run  farther  than 


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EXERCISE  7 

the  220-yard  dash.  Cross-country  running  and  distance 
runs  should  be  reserved  for  college  days.  The  marathon, 
or  even  modified  marathon  run,  is  fraught  with  the  grav- 
est danger  to  heart  and  kidneys,  as  shown  by  the  work  of 
W.  L.  Savage  of  New  York. 

No  boy  should  be  allowed  to  participate  in  more  than 
one  major  sport  at  one  time,  and  intervals  between  train- 
irig'seasons  are  desirable.  Many  breakdowns  occur  from 
indulging  in  athletics  when  suffering  from  slight  illness, 
such  as  tonsillitis,  or  attempting  to  return  to  sport  too 
soon  after  the  cardiac  muscle  has  been  impaired  by  the 
toxins  of  disease. 

The  recent  rapid  growth  of  girls'  athletics  has  brought 
us  face  to  face  with  the  same  problems  in  regard  to  heart 
strain  or  overindulgence  that  we  have  found  in  athletic 
training  for  boys.  My  experimental  study,  *  *  The  Effect 
on  the  Heart  Rate  and  Blood  Pressure  of  Vigorous  Ath- 
letics in  Girls,*'  American  Physical  Education  Review, 
1914,  showed  that  even  such  violent  sports  as  basketball 
and  track  athletics  were  extremely  beneficial  when  prop- 
erly safeguarded. 

In  regard  to  girls'  athletics,  the  work  of  Dr.  Clelia  D. 
Mosher  of  Stanford  University,  and  others,  has  modified 
greatly  our  ideas  in  regard  to  the  proper  relation  between 
exercise  and  menstruation.  It  seems  to  be  the  unanimous 
belief  that  we  may  safely  be  much  more  liberal  in  our 
exercise  allowance  at  that  time;  that  marching  tactics, 
calisthenics,  and  club  swinging  have  a  distinctly  benefi- 
cial effect  in  lessening  pain  and  disability.  This  is  un- 
doubtedly the  result  of  a  redistribution  of  the  circulation 


\ 


8  PHYSICAL  RECONSTRUCTION 

and  improved  mental  attitude.  In  fact,  it  is  emphasized 
that  the  psychical  attitude  is  of  great  importance,  and 
that  the  girl  should  be  discouraged  from  thinking  of  this 
perfectly  normal  function  in  terms  of  illness.  Among  col- 
lege women  Dr.  Mosher  and  others  have  succeeded  in 
lessening  the  pain  and  disability  to  a  very  marked  degree 
by  exercise  and  treatment,  the  fundamental  part  of  such 
a  program  being  deep  abdominal  breathing  with  jin- 
creased  use  of  the  diaphragm  by  training.  This  may  be 
done  with  the  patient  lying  supine  and  her  effort  directed 
toward  raising  and  lowering,  to  as  great  an  extent  as 
possible,  a  moderately  heavy  book  placed  upon  the  abdo- 
men. The  more  violent  types  of  athletics,  including  jump- 
ing and  running,  should  be  interdicted  for  at  least  three 
days  and  longer,  when  necessary,  in  any  individual  case. 
I  am  convinced  that  we  are  only  at  the  beginning  of  our 
knowledge  of  the  possibilities  of  woman's  physical  devel- 
opment. Already  in  such  a  sport  as  track  athletics,  in 
spite  of  their  very  recent  development  and  meager  oppor- 
tunities, girls  are  making  records  in  the  different  events, 
which  range  from  two-thirds  to  three-quarters  of  those 
records  made  by  our  Olympic  champion  athletes.  Those 
invaluable  traits  of  character,  loyalty,  unselfishness,  self- 
control,  and  the  team-work  ideal,  are  developed  by  ath- 
letics as  in  no  other  way.  I  have  not  seen,  in  my  ex- 
perience, the  slightest  tendency  for  athletics,  developed 
by  coaches  with  the  proper  ideals,  to  make  girls  in  any 
way  less  womanly. 

The  sudden  secession  from  regular  exercise,  which 
usually  comes  at  the  end  of  school  and  college  life,  is 


EXERCISE  9 

something  which  should  not  he  allowed  to  occur.  From 
the  vigorous  games  of  youth  the  transition  should  he 
made  through  the  gymnasium,  volley  ball,  and  tennis  to 
such  sports  as  hiking  and  golf,  which  can  be  followed 
throughout  life.  This  principle  should  be  applied  to  both 
sexes.  In  general,  it  is  well  for  the  physician  to  keep  in 
mind  that,  after  a  great  deal  of  painstaking  study,  physi- 
cal educators,  as  a  rule,  have  come  to  the  following  con- 
clusions: 1.  That  exercises  of  speed,  those  exercises  in 
which  a  certain  distance  is  covered  in  the  shortest  time, 
are  not  suited  in  their  severe  forms  except  to  persons 
in  good  condition  from  eighteen  to  thirty-five.  2.  That 
exercises  of  strength,  which  require  all  of  one's  energy  to 
perform — for  instance,  weight  throwing,  weight  lifting, 
and  apparatus  work — are  suited  to  the  ages  of  twenty 
to  thirty-five.  3.  That  exercises  of  endurance,  which  con- 
stitute many  and  rhythmical  repetitions  of  easy  move- 
ments, such  as  distance  running,  walking,  bicycle  riding, 
etc.,  are  suited  to  any  age  up  to  fifty  (they  are  self- 
limited  in  childhood),  the  only  exception  being  the  period 
of  accelerated  growth,  as  regards  games  and  distance 
running,  before  mentioned.  4.  That  exercises  of  skill 
such  as  golf,  archery,  quoits,  etc.,  are  suitable  through 
all  one's  active  life,  and  are  invaluable,  especially  after 
fifty. 

Many  games,  such  as  tennis,  may  partake  of  several 
or  all  of  these  types,  and  in  advising  in  regard  to  them 
one  should  be  guided  by  the  other  general  principles 
already  outlined. 

I  have  appended  a  simple  drill  of  ''setting-up  exer- 


10  PHYSICAL  RECONSTRUCTION 

cises"  which  will  make  for  general  development,  and  a 
set  of  exercises  on  the  chest  weights,  which  may  be  used 
in  the  same  way,  but  which  is  mainly  intended  to  exercise 
fully  both  actively  and  passively  each  possible  joint. 
These  chest-weight  movements  will  greatly  assist  in 
the  return  of  function  after  the  disability  following 
fracture,  dislocation,  or  arthritis. 

Therapeutic  Exercise. — Turning  from  the  value  of  ex- 
ercise, as  a  means  of  upbuilding  and  retaining  general 
health,  to  exercise  as  a  purely  therapeutic  measure,  there 
are  several  things  to  be  considered.  In  the  treatment  of 
patients  by  exercise  much  more  enters  into  the  problem 
than  the  conditions  relating  to  the  involved  group  or 
groups  of  muscles.  The  inheritance  of  the  patient,  the 
environment  in  which  he  has  been  and  that  in  which  he 
must  remain  during  the  treatment,  and  the  special  eifect 
of  his  stage  of  development  must  all  be  carefully  con- 
sidered. The  importance  of  the  last  fact  has  been  too 
often  overlooked.  For  example,  as  E.  H.  Arnold  of  New 
Haven  has  emphasized,  in  the  giving  of  corrective  exer- 
cises to  children  during  accelerated  growth,  more  harm 
than  good  is  often  done  by  overload  of  work  or  by  the 
superimposing  of  a  strenuous  exercise  regime  on  the  al- 
ready too  severe  strain  of  growth,  development,  and 
school  life,  which  the  child  is  carrying.  Furthermore,  we 
must  expect  a  far  different  reaction  to  exercise  treat- 
ment on  the  part  of  a  patient  who  has  left  the  ''elastic 
age"  of  youth  and  entered  the  "connective  tissue  age(' 
of  middle  and  late  life.  It  is  also  the  physiological  and 
not  the  chronological  age  which  it  is  essential  to  keep  in 


Fig.  3.    Severe  Shrapnel  Wound  of  Left  Shoulder  with  Compound  Com- 
minuted Fracture  of  6th  and  7th  Ribs. 

X-Ray  shows  entire  body  of  scapula  missing,  glenoid,  coracoid  and  acromion 
processes  intact.  Piercing  fracture  of  ribs.  Movements  at  shoulder  limited  to 
40°  of  flexion  and  20°  of  abduction.  After  four  weeks  of  massage  and  exercise 
active  flexion  to  80°,  abduction  to  50°. 


EXEKGISE  13 

mind,  as  has  been  pointed  out  by  C.  W.  Crampton  of 
Battle  Creek.  We  have  found  in  the  New  Haven  Ortho- 
pedic Dispensary  many  cases  of  children  who  had  to  be 
taken  from  home  surroundings  for  the  simple  purpose 
of  supplying  them  for  a  sufficient  period  of  time  with 
adequate  nourishment  before  the  special  treatment  out- 
lined could  be  expected  to  achieve  the  desired  result. 

There  are  four  main  types  of  exercise  used:  (a)  that 
done  entirely  by  the  operator  (passive) ;  (b)  that  done 
by  the  patient  assisted  in  varying  degrees  by  the  opera- 
tor (assistive) ;  (c)  that  done  wholly  by  the  patient 
(active) ;  (d)  that  done  by  the  patient  opposed  by  the 
operator — ^weights,  friction,  or  the  opposing  group  of 
muscles  (resistive).  The  muscular  contraction  in  the  last 
type  has  been  further  divided  into  three  varieties,  ac- 
cording to  the  direction  of  the  movement  of  the  muscle 's 
insertion  in  relation  to  its  origin.  For  instance,  in  the 
contraction  of  the  biceps  when  opposed  by  the  action  of 
the  triceps  (self -resistive  exercise),  the  former  may 
slowly  overcome  the  pull  of  the  latter  and  its  origin  and 
insertion  be  brought  nearer  together — concentric  contrac- 
tion; or  the  power  of  both  may  be  equal,  so  that  the 
distance  between  the  origin  and  insertion  remains  un- 
changed— static  contraction;  or  the  pull  of  the  triceps 
may  be  greater,  bringing  further  apart  the  points  of  ori- 
gin and  insertion — eccentric  contraction. 

As  we  proceed  in  the  development  of  the  muscular  sys- 
tem certain  changes  in  structure  take  place.  With  in- 
creased bulk  and  tone  developed  by  exercise  there  is  a 
tendency  for  the  entire  body  of  the  muscle  to  shorten, 


14  PHYSICAL  KEGONSTRUCTION 

bringing  its  points  of  origin  and  insertion  nearer  to- 
gether. We  make  use  of  this  property  of  well-developed 
muscle  to  shorten  in  the  treatment  of  many  orthopedic 
conditions — for  instance,  in  a  round-shouldered  child  we 
exercise  particularly  the  muscles  of  the  upper  back,  there- 
by retracting  the  shoulders.  It  might  here  be  noted,  as 
will  be  emphasized  later,  that  disuse,  such  as  would  fol- 
low the  application  of  a  shoulder  brace  in  this  same 
group,  has  ultimately  the  opposite  effect,  namely,  to 
stretch  out  and  weaken  the  affected  muscles  and  to  in- 
crease the  slump.  This  shortening  of  the  stronger  mus- 
cles is  also  seen  where  there  is  a  lack  of  balance  in  the 
power  between  two  muscles  or  muscle  groups  having  an- 
tagonistic function  as,  for  instance,  following  partial 
paralysis.  The  less  affected  tends  to  shorten  at  the  ex- 
pense of  the  more  affected  muscle  or  muscle  groups. 

Muscles,  then,  are  elastic,  and  will  shorten  when  given 
the  opportunity.  If  this  condition  remains  long  enough, 
real  structural  shortening  ensues.  For  example,  the 
wearing  of  high  heels  for  many  years  has  a  marked 
tendency  to  produce  structural  shortening  of  the  calf 
muscle.  This  tendency  to  contraction  is  undoubtedly 
due  to  the  property  of  muscle  called  tone,  or  tonus. 
Muscle  tone  is  the  result  of  a  slight  constant  contraction 
of  many  of  the  fibers  of  any  healthy  muscle.  Tone  is 
increased  in  vigorous  bodily  health  and  well-developed 
muscle  and  in  response  to  mental  stimulus.  It  is  de- 
creased during  mental  depression,  bodily  weakness,  and 
sleep,  and  practically  lost  under  complete  anesthesia  or 
other  complete  loss  of  consciousness. 


EXERCISE  17 

Fatigue  is  a  sluggish  or  subnormal  response  of  a  mus- 
cle to  its  stimulus.  This  may  be  due  to  either  a  weak- 
ening of  the  stimulus  itself  following  injury  or  weakness 
of  the  neurone,  or  to  a  deadening  of  the  sensitivity  of  the 
end-plate  of  the  nerve  in  the  muscle  cell  by  the  accumu- 
lation of  fatigue  products.  The  first  fatigue  products 
are  stimulants  to  muscular  activity,  and  this  accounts 
for  the  fact  that  a  muscle  works  better  after  a  few  con- 
tractions than  at  first.  That  is  why  we  "warm  up"  a 
muscle  before  severe  exertion. 

The  early  onset  of  fatigue  must  be  carefully  watched 
whenever  the  muscle  is  subnormal.  In  regard  to  general 
fatigue  the  point  is  often  overlooked  that  it  is  cumulative 
in  its  effect.  This  means  that  a  little  more  work  done 
by  a  fatigued  muscular  system  calls  for  the  expenditure 
of  a  tremendous  amount  of  nervous  energy. 

Remedial  gymnastic  programs  for  the  various  ortho- 
pedic conditions — infantile  paralysis,  kyphosis,  lordosis, 
scoliosis,  flat  feet,  etc.,  are  fully  given  in  the  sections 
where  each  is  discussed. 

CHEST  WEIGI^T  EXERCISES. 

The  position  assumed  for  active  flexion  gives  passive  extension, 
and  vice  versa. 

Unless  otherwise  stated,  the  use  of  the  shoulder  height  weights 
is  indicated. 

1.  Wrist. 
A.  Flexion. 

Patient  stands  with  back  of  hand  toward  weights,  arms 
extended  downward  and  flexes.     (Passive  extension.) 


18  PHYSICAL  EECONSTRUCTION 

B.  Extension. 

Patient  stands  with  palm  of  hand  toward  weights,  arms  ex- 
tended downward  and  extends.     (Passive  flexion.) 

2.  Elbow. 

A.  Flexion. 

1.  Patient  stands  facing  weights,  arms  extended  forward. 

Flex,  extend. 

2.  Overhead  weights.    Arms  extended  upward,  hands  en- 

cased in  gloves  and  bound  to  handles  if  necessary. 
Flex,  extend. 

B.  Extension. 

1.  Patient  stands  with  back  to  weights,  elbow  flexed  shoul- 

der high  and  rope  over  shoulder.    Extend,  flex. 

2.  Overhead  weights.    With  arms  at  side,  let  weights  flex 

elbow.    Extend,  flex. 

C.  Pronation. 

Patient  stands  affected  side  toward  weights,  elbow  flexed, 
and  fixed  at  side  by  other  hand  or  by  operator.  Lower 
forearm  across  body  and  return. 

D.  Supination. 

Patient  stands  unaffected  side  toward  weights,  elbow 
flexed  and  fixed  at  side  by  other  hand  or  by  operator. 
Draw  forearm  up  and  sideward  and  return. 

3.  Shoulder. 
A.  Flexion. 

1.  Floor  or  shoulder  weights. 

a.  Patient  stands  facing  weights,  arms  extended  for- 
ward, supinated  or  pronated.  Lower  arms  and 
raise. 

5.  Patient  lying  supine,  head  toward  weights,  arms 
extended  upward.  Lower  arms  fore — downward 
to  sides  and  raise. 

2.  Overhead  weights. 

Arms  extended  upward,  lower  fore — downward  and 
raise. 


EXERCISE  19 

B.  Extension. 

1.  Floor  or  shoulder  weights. 

CL  Patient  stands  with  back  to  weights,  arms  extended 

downward.    Raise  arms  forward  and  return. 
h.  Patient  lies  supine,  feet  toward  weights.     Raise 
arms  fore — upward  and  return. 

C.  Abduction. 

1.  Patient  stands  unaffected  side  toward  weights,  affected 

arm  across  body. 

a.  Abduction  in  a  lateral  plane,  elbow  flexed.  Ex- 
tend elbow.     Keep  at  shoulder  level.     Return. 

h.  Carry  straight  arm  forward  and  sideward  at  shoul- 
der level.    Return. 

2.  Floor  weights. 

Patienl  lies  supine,  feet  to  weights.  Raise  arm  side- 
ward, return. 

D.  Adduction. 

1.  Patient  stands,  affected  side  toward  weights,  arm  ex- 

tended, shoulder  level.  Carry  arm  forward  across 
chest,  keeping  straight  or  flexing  elbow,  then  ad- 
ducting  shoulder.    Return. 

2.  Floor  weights. 

Patient  lies  supine,  head  to  weights,  arm  extended 
upward.    Lower  sideward,  raise. 

3.  Overhead  weights. 

a.  From  extended  arm.    Lower  and  raise. 

(1)  Carry  arm  obliquely  fore — downward. 

(2)  Carry  arm  side — downward. 

(3)  Carry  arm  obliquely  back — downward. 

Combination  of  adduction  and  abduction. 

Raise  arm  sideward  to  shoulder  level,  carry  forward  and 
return,  carry  backward  and  return. 


20  PHYSICAL  RECONSTRUCTION 

4.  Trunk. 

Resistance  to  forward,  backward,  and  lateral  bending  of 
the  trunk  is  obtained  by  fixing  the  handle  of  the 
weights  at  given  points  in  relation  to  the  trunk.  The 
higher  the  weight  is  fixed,  the  greater  the  resistance 
given.  The  weight  may  be  fixed  on  abdomen,  chest, 
head,  or  arms  extended  over  the  head. 

5.  Thigh.    Foot  bound  to  handle  by  special  slipper  or  loop  at- 

tached to  shoe. 

A.  Flexion. 

1.  Floor  attachment. 

a.  Patient  supine,  feet  toward  weights,  knee  flexed  or 

straight.     Flex,  extend. 
h.  Patient  lying  on  side,  feet  toward  weights,  knee 

flexed  or  straight.    Flex,  extend. 
c.  Patient  standing,  back  to  machine.    Flex,  extend. 

B.  Extension. 

1.  Floor  attachment. 

a.  Patient  supine,  head  toward  weights,  knee  flexed 

or  straight.    Extend,  flex. 
h.  Patient  lying  on  side,  head  toward  weights,  knee 

flexed  or  straight.    Extend,  flex. 
c.  Patient  standing,  facing  weights.     Extend,  flex. 

C.  Abduction. 

1.  Floor  attachment. 

Patient  stands  or  lies  supine,  unaffected  side  toward 
weights.    Abduct,  return. 

D.  Adduction. 

1.  Floor  attachment. 

Patient  stands  or  lies  supine,  affected  side  toward 
weights.    Adduct,  return. 

E.  Rotation. 

1.  Floor  attachment. 

Patient  lies  prone,  knee  flexed,  side  toward  weights. 
(a.  Unaffected  side  for  inward  rotation,    h.  Af- 


Fig.  6.    Chipping  of  Humeral  Head  and  Extensive  Wound  of  Shoulder. 
No  active  motion  at  first.    Flexion  after  five  weeks  of  massage  and  exercises. 

Fig.  7.     Abduction  Assisted  Largely  by  Scapular  Rotation  well  Con- 
trolled. 

Fig.  8.  Hyperextension  Limited  by  Scar  Tissue  and  Adhesions. 


EXERCISE  23 

fected  side  for  outward.)     Rotate  by  swinging 
foot  sideward. 
6.  Knee.    Foot  bound  to  handle. 

A.  Flexion. 

1.  Floor  attachment. 

a.  Patient  stands  facing  weights.    Flex,  extend. 

b.  Patient  lies  prone,  feet  toward  weights.    Flex,  ex- 

tend. 

B.  Extension. 

1.  Floor  attachment. 

a.  Patient  stands  back  to  weights,  knee  flexed.    Ex- 

tend, flex. 

b.  Patient  lies   prone,   head   toward  weights,   knee 

flexed.    Extend,  flex. 

Setting-up  Exercises. 

1.  a.  Arms  to  thrust  raise,  thrust  forward,  return,  lower. 

b.  Arms  to  thrust  raise,  thrust  sideward,  return,  lower. 

c.  Arms  to  thrust  raise,  thrust  upward,  return,  lower. 

2.  Hands  on  hips. 

a.  Heels  raise,  lower. 

b.  Toes  raise,  lower. 

c.  Heels  raise,  knees  deep  bend,  knees  straighten,  heels 

lower. 

3.  Hands  on  hips. 

a.  Trunk  sideward  right  bend,  raise,  bend  sideward  left, 

raise. 

b.  Trunk  sideward  right  turn,  return,  turn  sideward  left, 

return. 

c.  Trunk  lower  forward,  raise,  bend  backward,  raise. 

4.  a-.  Arms  forward    raise,  carry  sideward,  carry  forward, 

lower. 
b.  Arms  sideward    raise,  carry  forward,  carry  sideward, 
lower. 


24  PHYSICAL  RECONSTRUCTION 

e.  Arms  forward    raise,  carry  upward,  lower  forward, 

lower  downward. 
d.  Arms  sideward   raise,  carry  upward,  lower  sideward, 

lower  downward. 

5.  Hands  on  hips. 

a.  Raise  right  knee,  lower. 
&.  Raise  left  knee,  lower. 

c.  Raise  right  knee,  extend  leg  forward,  bend  knee,  lower. 

d.  Raise  left  knee,  extend  leg  forward,  bend  knee,  lower. 

6.  Jump  to  stride  stand,  arms  raise  sideward. 

€b.  Trunk  bending,  alternating  right  and  left. 
h.  Trunk  turning,  alternating  right  and  left, 
c.  Hands  behind  head. 

Trunk  bending  alternately  forward  and  backward. 

7.  Stationary  running  on  toes  with  high  knee  raising. 


Fig.  10.    Baking.    Electric  Light  Bath  of  Knee. 
Fia.  11.    Diathermy.    Electrical  Heat  Penetration  for  Deep  Hyper^bmia. 


Chapter  II 

BAKING— HYDROTHERAPY— ELECTRO- 
THERAPY 

.      BAKING 

The  result  of  the  treatment  of  a  part  of  the  body  by 
superheated  dry  air  is  to  cause  a  local  dilatation  of  the 
skin  and  subcutaneous  capillaries,  thereby  thinning  their 
cell,  walls  and  increasing  the  intercellular  spaces.  A 
greatly  increased  amount  of  blood  serum  with  its  con- 
tained food  is  thus  permitted  to  pass  out  and  supply  the 
tissue  cells.  This,  and  the  increased  removal  of  waste 
brought  about  by  the  accompanying  stimulation  of  the 
lymphatic  circulation,  are  the  two  essential  factors  in 
shortening  the  period  of  tissue  repair. 

The  common  means  employed  to  obtain  this  result  are : 
First,  electric  lights  with  reflectors,  such  as  the  thermo- 
light;  second,  the  adjustable  local  electric  light  bath 
(Burdick) ;  third,  Kellogg 's  thermophore;  fourth,  the 
electric  light  body  cabinet ;  and  fifth,  the  various  types  of 
ovens  heated  by  gas  and  alcohol,  some  of  which  are  quite 
inexpensive.  For  the  application  of  heat  to  the  deeper 
tissues,  machines  for  electric  heat  penetration  are  used. 
The  average  length  of  treatment  is  twenty  minutes.  In 
baking,  the  part  must  be  well  wrapped  in  a  dry  towel. 

27 


28  PHYSICAL  RECONSTRUCTION 

Watch  for  scars  or  anesthetic  areas.    The  heat  is  given 
at  250  to  400  degrees. 

Passive  Hyperemia.  This  method  of  increasing  local 
blood  supply  by  means  of  the  constriction  band  placed 
proximally  to  the  part,  tight  enough  to  shut  off  the  venous 
return  but  not  to  impede  the  arterial  inflow,  is  usually  re- 
ferred to  as  the  Bier  treatment.  This  method  should 
precede  the  other  types  of  treatment  indicated  on  the 
part  and  its  duration  should  not  exceed  ten  minutes.  It 
is  a  valuable  method  of  obtaining  passive  hyperemia, 
especially  in  selected  cases  where  means  of  procuring  ac- 
tive hyperemia  are  not  available. 

HYDKOTHEEAPY 

Definition.  Hydrotherapy  is  the  application  of  water 
to  the  surface  of  or  within  the  body  for  the  relief  of 
diseased  condition. 

History.  The  therapeutic  value  of  this  agent  was 
known  to  the  Egyptians,  Chinese,  Greeks,  Romans  and 
Arabs.  Modem  use  of  water  for  curative  purposes  be- 
gan in  the  sixteenth  century  in  Italy,  France  and  Eng- 
land, as  shown  in  the  writings  of  Lanzani,  Barra,  Wesley, 
CuUen  and  Floyer.  In  the  United  States  Rush,  Lockette, 
Bell  and  others  have  added  to  our  knowledge  of  this 
form  of  treatment.  Among  modem  writers  none  have 
contributed  more  than  Kellogg  of  Battle  Creek. 

At  the  present  time  the  use  of  hydrotherapy  is  being 
greatly  extended  and  its  value  more  largely  recognized. 
While  our  larger  sanitaria  and  hospitals  have  expensive 


HYDROTHERAPY— ELECTROTHERAPY   29 

equipments,  it  is  possible  to  obtain  most  of  the  funda- 
mental benefits  from  the  various  forms  of  treatment  with 
very  simple  apparatus. 

Properties.  The  physical  properties  of  water  are  all 
made  use  of  in  our  treatment.  Its  different  forms — solid, 
liquid  and  gas — all  have  their  places.  Added  value  is  de- 
rived from  the  ability  of  the  water  to  hold  certain  salts 
and  minerals  in  solution.  Varying  degrees  of  the  tem- 
perature of  the  water  used,  and  the  force  and  amount 
in  which  it  is  applied,  each  affect  the  result  of  the  treat- 
ment. 

Effect.  The  main  desired  result  is  obtained  through 
the  thermal  and  mechanical  effect  of  the  application  of 
water  on  the  sensory  nerve  endings  in  the  skin.  Re- 
flexly,  changes  are  brought  about  in  the  circulation  and 
nervous  system. 

Circulation,  (a)  Distribution  of  the  blood.  The  appli- 
cation of  hot  water  brings  about  a  local  hyperemia.  Cold 
water  induces  vasomotor  contraction  in  the  skin  and 
dilatation  in  the  deeper  tissues,  followed  later  by  cuta- 
neous dilatation. 

(b)  Composition  of  the  blood.  A  redistribution  of  the 
blood  cells  shows  a  marked  increase  in  the  red  blood  cell 
count  in  the  circulation. 

(c)  Changes  in  blood  pressure.  By  increasing  the  skin 
elimination  of  toxins  and  blood  vessel  dilatation,  we  are 
able  to  reduce  high  blood  pressure.  Hot  and  tepid  baths 
are  used.  The  stimulating  effect  of  cold  baths  will  im- 
prove capillary  tone  and  raise  the  pressure  when  below 
normal. 


30  PHYSICAL  RECONSTRUCTION 

Respiration.  A  tonic  bath  will  induce  deep  breathing 
and  raise  the  general  body  tone. 

Nervous  SysteWr.  (a)  Stimulation  of  the  nervous  sys- 
tem is  secured  by  the  various  tonic  baths.  Vigorous  rub- 
bing and  massage  are  helps  in  securing  this  result.  Often 
a  hot  bath  will  act  as  a  stimulant. 

(b)  Sedative  effect  on  the  nervous  system  is  obtained 
by  a  long  continued  tepid  bath. 

Muscular  System.  The  removal  of  local  and  the  les- 
sening of  systemic  fatigue  is  possible  by  means  of  the 
tonic  bath. 

Skin.  The  direct  effect  of  water  applied  to  the  skin 
is  that  of  a  mechanical  irritant.  This  action  may  be  in- 
creased by  the  use  of  salt,  etc.  The  circulatory  effect  has 
been  described.  The  removal  of  waste  matter  is  best  ac- 
complished by  warm  water.  Cold  water  stimulates,  closes 
the  pores  and  protects  against  cold. 

Body  Temperature.  Cold  water  is  now  used  freely 
to  lower  body  temperature  in  typhoid,  heat  stroke,  etc. 
It  may  safely  be  repeated  several  times  daily  if  neces- 
sary. It  is  a  good  general  rule  preceding  every  bath  to 
heat  the  body.  Methods  in  common  use  are  the  blanket 
pack,  electric  cabinet,  electric  cradle,  or  exercise. 

Electric  Cradle  or  Cabinet  Bath.  In  using  the  cradle 
(which  is  a  frame  wired  with  lights  fitting  over  the  pa- 
tient in  bed)  or  the  cabinet  (lined  with  lights  in  which 
the  patient  sits)  cover  the  head  with  ice  cap  or  cold  wet 
towel.  Take  the  temperature  often  and  discontinue  the 
treatment  when  the  temperature  has  reached  100  degrees 
or  the  patient  perspires  freely.    Indications — All  forms 


Fig.  11a.    Multiplex  Sinusoidal  Machine. 


Fig.  lib.     High  Fpequency  Machine. 


Fig.  11c.     Alpine  Sun  Lamp,  Ultra  Violet  Ray. 


HYDROTHERAPY— ELECTROTHERAPY   33 

of  intoxication,  gout,  nephritis  and  the  relief  of  internal 
congestion. 

Wet  Pack.  Wrap  the  patient  in  a  wet  sheet  and  then 
several  blankets.  Be  careful  not  to  have  the  surfaces  of 
the  body  touching.  Cold  packs  stimulate,  warm  ones 
soothe.  Treatment  should  average  about  an  hour  or  to 
desired  physiological  effect,  and  be  followed  by  rest. 

Evaporation  Pack.  This  type  of  tonic  treatment  is 
given  for  fifteen  or  twenty  minutes.  Cover  patient  with 
wet  sheet  and  one  loose  blanket.  It  may  be  given  locally 
as  a  compress,  or  as  a  body  pack.  It  is  well  to  use  a  head 
compress  also. 

Neptune  Girdle.  Two  sizes  of  binder  15"  by  60''  and 
18"  by  72"  will  serve.  Wrap  the  patient's  abdomen  in 
the  wet  linen  binder  and  cover  with  dry  flannel  one  slight- 
ly larger,  being  careful  to  exclude  the  air.  Indications — 
Nervousness,  insomnia,  nausea  and  digestive  dis- 
turbances. 

Abdominal  Coil.  Put  on  the  linen  binder,  then  the  coil, 
then  flannel  binder.  Run  water  through  coil  120  degrees 
for  15  minutes;  remain  the  rest  of  the  hour. 

Local  compresses  are  used  to  relieve  hyperemia. 

Simple  Tonic  Bath.  Sponge  bath;  apply  water  with 
slight  friction  with  hand  or  cloth. 

Half  Bath.  Tub  half  full  of  water  at  85  degrees  lower 
to  70  degrees  or  65  degrees.  Pour  water  over  the  patient 
and  rub  with  the  hand;  sit  three  to  five  minutes,  then 
apply  the  cooler  water. 

Drip  Sheet.  Stand  in  a  tub  of  hot  water.  Hold  the 
sheet  so  that  one-third  is  in  one  hand  and  two-thirds  in 


34  PHYSICAL  RECONSTRUCTION 

the  other.  Dip  in  water;  lift  out  and  wrap  around  pa- 
tient' and  pour  on  more  water — duration  three  to  five 
minutes. 

Sitz  Bath.  Sit  in  sitz  bath,  place  feet  in  bath  tub. 
Apply  water  80  degrees  to  60  degrees.  Keep  rubbing  the 
skin,  the  patient  rubbing  the  thighs  and  the  operator  rub- 
bing the  shoulders  and  back.  For  bladder  disturbances, 
pelvic  congestion. 

Use  hot  water  for  spasms,  colic  or  chronic  intestinal 
conditions.  The  body  surface  should  be  flushed  with 
heat,  followed  by  a  cold  shower  to  get  a  good  reaction  or 
the  patient  put  to  bed  with  the  room  at  an  even  tempera- 
ture till  the  vessels  regain  their  equilibrium.  For  con- 
ditions following  shell  shock,  irritable  heart,  hallucina- 
tions, fearful  dreams,  and  neurasthenia,  the  bath  at  94 
degrees  is  kept  up  for  an  hour  or  more. 

Douche.  Treatment  begins  with  water  90  degrees,  ris- 
ing to  115  degrees  and  ending  with  60  degrees.  Continue 
for  two  minutes. 

Scottish  Douche.  Two  jets,  one  100  degrees,  the  other 
60  degrees,  applied  alternately  by  a  lateral  sweep  of  the 
nozzle  up  and  down  the  spine. 

Whirl  Bath.  For  sensitive  stumps  or  masses  of  scar 
tissue,  treatment  by  whirling  water  at  95-110  degrees, 
mixed  or  unmixed  with  air,  leads  to  a  very  marked  reduc- 
tion of  sensitiveness  and  to  active  hyperemia,  and  is  an 
invaluable  means  of  the  preparation  of  the  part  for 
massage  or  exercise. 


HYDROTHERAPY— ELECTROTHERAPY   35 

ELECTEOTHEBAPY 

This  important  type  of  treatment  is  being  rapidly  de- 
veloped and  the  scope  of  its  usefulness  greatly  enlarged. 
It  is  essential  that  the  student  of  electrotherapeutics  have 
the  elemental  facts  outlined  for  him  in  the  simplest  pos- 
sible form. 

The  therapeutic  effects  of  electricity  are  to  produce 
surface  or  deep  hyperemia;  to  induce  muscular  contrac- 
tion, either  by  changes  in  the  chemical  reaction  within 
the  muscle  or  through  its  nerve  supply;  to  soften  scar 
tissue ;  to  hasten  the  healing  of  open  wounds ;  to  soothe 
nerve  irritation  and  to  cause  the  direct  absorption  of 
drugs  by  ionization. 

Electricity  is  produced  by  chemical  action,  induction 
or  friction,  all  of  which  types  are  used  in  the  treatment 
of  patients. 

The  type  of  current  produced  by  chemical  action  is 
generated  in  the  galvanic  cell  as  typified  by  the  standard 
Daniell  cell,  which  generates  an  electro-motive  force  of 
one  volt.  The  simplest  form  of  this  cell  is  a  quart  jar 
two-thirds  full  of  sulphuric  acid,  in  which  is  placed  a 
plate  of  zinc,  the  negative  pole  or  cathode,  and  a  plate  of 
carbon,  the  positive  pole  or  anode.  If  a  wire  is  placed 
between  the  upper  extremities  the  current  will  flow  from 
the  positive  to  the  negative  pole.  In  the  solution  there 
is  a  transfer  of  electricity  from  the  zinc  to  the  carbon. 
During  this  process  bubbles  of  hydrogen  form  around  the 
carbon.  This  is  called  polarization  and  may  be  great 
enough  to  block  the  current,  in  which  case  the  carbon 


36  PHYSICAL  RECONSTRUCTION 

should  be  removed  and  cleaned.  In  the  dry  cell  a  solid 
substance  replaces  the  sulphuric  acid,  but  the  action  is 
practically  the  same.  Electric  force  may  be  either  nega- 
tive or  positive  in  quality.  Like  types  repel  and  unlike 
types  attract  each  other. 

The  definition  of  a  few  electrical  terms  is  here  in  order. 

1.  Volt.  That  unit  of  electro-motive  force  generated 
by  the  standard  Daniell  cell. 

2.  Ohm.  The  unit  of  resistance  to  the  current  offered 
by  one  thousand  feet  of  one-tenth  inch  copper  wire. 

3.  Ampere.  The  unit  of  quantity  of  current  which  the 
force  of  one  volt  will  drive  through  one  ohm  in  one  sec- 
ond. 

McKenzie,  Strong  and  others  illustrate  the  meaning 
of  these  terms  by  the  comparison  of  electricity  to  water 
power.  If  one  water  container  is  placed  above  another, 
the  force  exerted  by  the  water  in  the  upper  container  in 
seeliing  the  level  of  the  lower  is  directly  proportionate  to 
the  difference  in  height,  and  is  comparable  to  the  reaction 
between  the  positive  and  negative  poles.  The  difference 
in  height  represents  potential  energy  and  this  force  cor- 
responds to  the  voltage  of  an  electric  current.  The 
amount  of  water  allowed  to  flow  from  the  upper  to  the 
lower  container  corresponds  to  the  amperage  of  an  elec- 
tric current.  Upon  the  size  of  the  pipe  used  depends 
the  amount  and  force  of  the  stream  of  water.  If  a  small 
pipe  is  used  the  resistance  (number  of  ohms)  is  increased, 
the  force  of  the  flow  (voltage)  is  high  but  the  quantity 
of  water  (amperage)  is  small.    On  the  other  hand,  if  a 


HYDROTHERAPY— ELECTROTHERAPY   39 

large  pipe  is  used  the  resistance  is  decreased  and  the  force 
is  lessened  but  the  quantity  of  flow  is  increased. 

In  electrotherapy  the  type  of  current  commonly  used 
has  relatively  high  voltage  but  very  low  amperage,  which, 
for  convenience,  is  measured  in  milliamperes. 

Galvanism.  The  ordinary  galvanic  battery  consists  of 
a  cabinet  containing  a  series  of  cells  joined  to  a  switch- 
board with  binding  poles,  to  which  are  attached  the  cords 
and  electrodes  for  applying  the  current  to  the  patient. 
There  are  also  appliances  for  measuring,  interrupting  or 
increasing  the  current. 

The  galvanic  is  a  continuous  current  flowing  steadily 
from  positive  to  negative.  It  is  used  for  the  following 
physiological  effects :  stimulation,  sedation,  nutrition  and 
chemical  changes.  Quite  different  effects  are  produced  by 
the  positive  and  negative  poles.  There  are  two  simple 
tests  for  differentiating  the  poles.  If  the  ends  of  the 
cords  are  placed  on  blue  litmus  paper  the  positive  pole, 
because  of  its  attraction  of  acids,  will  turn  the  paper 
pink.  If  the  cords  are  dipped  into  salt  solution  bubbles 
will  collect  around  the  negative  pole,  which  attracts  alka- 
lines.  Where  the  anode  or  positive  pole  is  used,  circula- 
tion, muscular  contraction  and  nervous  irritability  are  re- 
duced. At  the  point  of  application  of  the  cathode  there 
is  greater  muscular  contraction,  stimulation  of  circula- 
tion and  increased  nervous  irritability.  Having  selected 
the  proper  electrodes  for  the  desired  effect,  they  should 
be  applied  smoothly  and  firmly  to  unabraded  skin.  It 
must  be  remembered  that  the  electrodes  should  be  cov- 
ered with  smooth  felt  or  gauze  thoroughly  saturated  in 


40  PHYSICAL  RECONSTRUCTION 

warm  salt  solution  and  should  be  proportionate  in  size 
to  the  part  treated.  Burns  are  most  likely  to  occur  at  the 
cathode  and  this  point  should  be  most  carefully  watched. 
The  current  should  always  be  applied  and  decreased  slow- 
ly. This  type  of  current  is  also  applied  by  local  bath 
with  one  pole  in  the  water,  the  other  on  the  spine. 

Ionization.  Ionization  is  the  induction  of  drugs  into 
the  tissues  by  electrolysis.  These  substances  in  solution 
may  be  driven  in  by  the  galvanic  current.  The  ions  of 
zinc,  copper  and  lithium,  being  electro-positive,  should 
be  placed  on  the  anode,  by  which  they  are  repelled.  The 
ions  of  chlorine,  potassium  and  iodine  are  electro-nega- 
tive and  are  repelled  by  the  cathode.  "Weak  solutions  of 
two  or  three  per  cent  are  usually  employed. 

Interrupted  Galvanic  Current.  The  constant  current 
has  no  effect  on  muscular  contraction,  but  when  it  is  sud- 
denly shut  off  and  again  applied  at  both  this  break  and 
make  of  the  current  a  contraction  is  produced.  The 
stronger  contraction  occurs  when  the  current  is  made  at 
the  cathode.  A  device  called  a  metronome,  attached  to 
the  instrument,  produces  this  effect. 

A  smoother  type  of  galvanic  current  is  the  sinusoidal 
galvanic,  a  current  which  flows  evenly  on  the  positive  and 
negative  side  alternately.  It  has  a  deeper  effect  on  mus- 
cular nutrition. 

Faradic  Current.  The  faradic  is  an  induced  alternat- 
ing current,  produced  by  charging  one  coil,  the  primary, 
which  then  becomes  an  electro-magnet  and  when  brought 
into  contact  with  a  secondary  coil  charges  it  also.  By 
variation  in  the  size  of  wire  or  the  number  of  windings 


HYDROTHERAPY— ELECTROTHERAPY   43 

on  the  secondary  coil,  the  voltage  of  the  current  may 
be  increased  or  * '  stepped  up. ' '  This  current  may  be  made 
and  broken  by  the  withdrawal  and  reinsertion  of  one  of 
the  coils  by  hand,  or  may  be  rapidly  done  by  mechanical 
interruption. 

The  faradic  gives  a  harsher  stimulus  than  the  galvanic 
and  acts  directly  through  the  nerves,  producing  a  defi- 
nite muscular  contraction  similar  to  that  of  a  normal 
muscle.  For  that  reason  one  electrode  should  be  placed 
on  a  main  nerve  trunk  proximately  to  the  muscle  to  be 
stimulated  and  the  other  should  be  placed  on  the  electro- 
motor point.  The  difference  in  polarily  is  slight,  there- 
fore differentiation  is  unnecessary.  The  close  similarity 
of  this  current  to  the  normal  nerve  impulse  makes  it  par- 
ticularly valuable  in  keeping  muscles  in  good  tone  when 
normal  exercise  is  impossible. 

Most  machines  for  the  therapeutic  work  combine  the 
galvanic  and  faradic  sinusoidal  currents  and  they  should 
therefore  be  used  selectively. 

Sinusoidal  Current.  The  sinusoidal  current  is  also  in- 
duced and  is  therefore  similar  to  the  faradic,  save  that 
it  passes  in  a  wave  from  zero  to  the  highest  force  on  the 
positive  side  and  then  back  through  zero  to  the  highest 
force  on  the  negative  side  and  then  flows  back  from  nega- 
tive to  positive.  This  surging  effect  produces  complete 
muscular  contraction,  but  is  somewhat  more  gradual  and 
therefore  more  pleasant  than  the  harsh  stimulus  of  the 
faradic. 

Bigh  Frequency.  This  is  an  induced  current  oscillat- 
ing from  one-half  to  five  million  alternations  a  second, 


44  PHYSICAL  EECONSTRUCTION 

with  high  voltage  and  low  amperage.  The  different  types 
— d'Arsonval,  Oudin  and  Tesla — are  all  used.  To  obtain 
the  current  a  resonator,  coil  (solenoid),  adjustable  spark- 
gap  and  Leyden  jar  condensers  are  used. 

Application  to  the  patient  is  made  by  means  of  vacuum 
electrodes  or  plates.  Marked  changes  in  metabolism  are 
produced  with  little  discomfort  on  the  part  of  the  pa- 
tient. 

Diathermy.  Another  common  use  for  this  type  of  cur- 
rent is  the  driving  of  heat  deep  into  the  tissues  by  means 
of  two  pliable,  flat  metal  electrodes  applied  on  opposite 
sides  of  the  part  to  be  treated.  These  electrodes  should 
be  smoothed  out  and  then  shaped  carefully  to  the  part 
and  held  firmly  in  place. 

The  resistance  by  the  body  increases  the  heat  which  in 
turn  produces  marked  deep  hyperemia.  In  this  way  we 
are  able  to  drive  heat  deep  into  the  tissue,  as  in  the  joint 
cavity,  and  to  prepare  a  part  for  massage  or  exercise 
treatments. 

Static  Electricity.  This  current  is  produced  by  the 
friction  of  revolving  glass  plates,  charging  brushes.  Holtz 
and  Wimshurst  machines  have  been  varied  for  special 
uses.     The  high  tension  obtained  requires  insulation. 

The  types  of  current  are  Morton  wave  for  general 
tonic,  simple  current  for  insomnia  and  ''breeze,*'  sedative 
effect  on  pain. 

Sun  Lamp.  By  means  of  the  quartz  lens  light  can  be 
split  into  its  component  parts  and  all  but  a  desired  wave 
length  excluded.     The  ultra-violet  or  actinic  rays  may 


HYDROTHERAPY— ELECTROTHERAPY   45 

thus  be  used  alone  for  the  chemical  effect.  These  rays 
have  a  marked  bactericidal  and  healing  action. 

The  patient's  body,  with  the  exception  of  the  part  to 
be  treated,  should  be  carefully  covered.  Operators  much 
exposed  should  wear  smoked  glasses.  An  average  ex- 
posure is  three  minutes  at  a  distance  of  eighteen  inches. 

Very  satisfactory  results  have  been  obtained  in  the 
quickened  healing  of  open  wounds  by  this  means  in  a 
number  of  our  base  hospitals  where  these  lamps  are 
in  use. 


Chapteb  III 
MASSAGE 

Definition.  Massage  is  the  scientific  manipulation  of 
the  soft  parts  of  the  living  body  for  purposes  of  health. 
It  is  a  mechanical  interference  with  and  modification  of 
the  physiological  function  of  the  different  tissues. 

History.  Throughout  the  animal  kingdom  we  find 
many  instances  of  one  animal  massaging  another  or  itself 
by  rubbing,  licking  or  biting  the  affected  part.  Among 
mankind  it  was  known  to  the  Chinese  at  least  three 
thousand  years  B.C.,  and  was  used  somewhat  by  the 
Egyptians  and  Greeks  and  by  the  Romans  in  their  baths. 
Among  the  Greeks,  ^sculapius  and  his  followers,  the 
Asclepiades,  in  their  school  of  medicine  on  the  Islands 
of  Kos  and  Knidus,  were  the  first  to  systematize  massage. 
With  the  other  arts  and  sciences  it  was  submerged  dur- 
ing the  dark^ages  to  reappear  on  the  teaching  of  Pare, 
Ling  and  Metzger  in  modem  history.  It  was  first  used 
extensively  in  this  country  by  Dr.  S.  Weir  Mitchell  about 
1877. 

Types  of  Movements.  There  are  four  cardinal  move- 
ments used: 

1.  Eflfleurage  or  stroking. 

2.  Petrissage.    Pinching  or  kneading. 

46 


Fig.  15.    Massage.    Effleurage  or  Stroking  of  Forearm. 
Fig.  16.    Massage,    Petrissage  or  Kneading  of  Calf. 


MASSAGE  49 

3.  Tapotement.    Hacking,  slapping  or  vibrating. 

4.  Frictions. 

Objects : 

1.  To  increase  arterial,  venous  and  lymphatic  flow. 

2.  To  improve  skin  function. 

3.  To  soothe  or  stimulate  the  nerves. 

4.  To  eliminate  waste  products. 

5.  To  break  down  adhesions. 

6.  To  reduce  swollen  tissue. 

7.  To  improve  nutrition. 

General  Considerations.  Since  by  means  of  massage 
we  are  going  to  interfere  with  the  physiologic  function 
of  tissue,  a  broad  and  thorough  knowledge  of  physiology 
is  an  absolutely  essential  basis  for  scientific  work.  Not 
only  the  way  tissues  and  organs  act,  but  their  structure 
and  location  must  be  exactly  known;  therefore  a  com- 
prehensive knowledge  of  the  anatomy,  at  least  of  the  soft 
parts  of  the  body,  is  of  extreme  importance.  The  too 
great  neglect  of  this  valuable  means  of  treatment  has 
been  to  a  large  extent  due  to  the  impression  left  on  both 
the  physician  and  the  public  through  the  ignorant  and 
unscientific  use  of  massage  by  a  large  proportion  of 
those  claiming  to  be  able  to  treat  by  this  means.  Al- 
though one  of  the  best  contributions  to  this  science  was 
made  by  the  Swedes,  many  valuable  features  have  since 
been  added  to  the  theory  and  application  of  this  form 
of  physical  therapy.  It  is  a  mistake,  then,  to  follow  the 
Swedish,  or  any  other  so-called  system,  to  the  exclusion 
of  others. 


50  PHYSICAL  RECONSTRUCTION 

The  proven  value  of  this  form  of  treatment,  and  the 
fact  that  in  so  many  serious  conditions  its  use  is  indi- 
cated, make  it  a  worthy  branch  of  the  medical  science. 
No  person  can  be  truly  successful  in  this  work  who  does 
not  approach  it  from  the  standpoint  of  service  and  who 
is  unwilling  to  make  the  personal  sacrifice  necessary  to 
gain  a  well .  rounded  knowledge  of  the  entire  subject. 
The  high  type  of  young  women  entering  the  work  for  the 
army  will  undoubtedly  elevate  the  plane  of  this  field  of 
endeavor.  Let  us  hope  that  in  the  mind  of  the  general 
public  the  athletic  ''rubber"  and  the  Turkish  bath  at- 
tendant will  be  hereafter  clearly  distinguished  from  the 
true  masseur  or  masseuse. 

The  close  personal  contact  with  the  patient  makes  it 
imperative  that  the  operator  remain  constantly  mindful 
of  the  fact  that  the  feeling  of  confidence  and  trust  on  the 
part  of  the  patient  is  an  invaluable  aid  toward  success. 
Dignity,  reserve  and  high  moral  tone  are  prerequisites. 

In  an  oiBfice  practice  it  is  desirable  to  have  a  couch  or 
a  padded  table  about  three  feet  high  and  two  feet  wide. 
The  best  temperature  is  from  70°  to  75°.  Only  the  part 
should  be  exposed  which  is  being  manipulated.  Both 
hands  should  be  trained  to  equal  skill  and  during  a  treat- 
ment are  usually  kept  in  contact  with  the  skin.  Powder 
is  being  increasingly  used  to  lessen  skin  friction  and  is 
in  many  ways  preferable  to  cocoa  butter,  cold  cream 
or  vaseline.  The  use  of  ichthyol  or  strong  liniments  to 
produce  counter-irritation  is  unnecessary.  The  length 
of  the  average  treatment  depends  upon  the  vigor  and 
concentration  of  effort,  the  object  desired,  and  the  size 


MASSAGE  53 

of  the  surface  to  be  covered,  and  varies  from  twenty  to 
fifty  minutes. 

Venous  Circulation.  Venous  circulation  runs  in  the 
same  direction  as  the  lymphatic  and  is  modified  by  the 
action  of  the  valves  scattered  throughout  the  venous  sys- 
tem. 

Lymphatic  Circulation.  Its  general  course  is  from  the 
extremities  toward  the  heart  and  is  modified  by  ** stops," 
individual  or  groups  of  glands. 

Arm.  From  the  tips  of  the  fingers  to  the  axilla,  espe- 
cially on  the,  flexor  side.  Gland  in  the  elbow,  middle  of 
the  arm  and  chain  in  the  axilla. 

Leg.  Largest  vessels  on  the  dorsum  of  the  foot,  the 
back  of  the  leg,  popliteal  space,  inner  side  of  the  thigh  to 
the  front  above.  Glands  between  the  tendo  Achillis  and 
external  malleolus,  the  lower  part  of  the  thigh  and  the 
chain  of  inguinal  glands  in  the  groin. 

Face.  The  upper  vessels  center  at  the  root  of  the  nose ; 
the  lower  ones  go  toward  the  neck. 

Neck.  Down  the  front  of  the  sterno-mastoid  and  in 
front  of  the  edge  of  the  trapezius,  where  most  of  the 
cervical  glands  are  located. 

Chest.  Superficial  glands  from  the  inner  third  of  the 
breast  toward  the  sternum,  outer  two-thirds  toward  the 
axilla.    Deep  vessels  toward  the  sternum. 

Abdomen.    Generally  toward  the  inguinal  glands. 

Back.  Superficial  circulation  of  the  upper  part  to- 
ward the  axilla ;  deep  circulation  toward  the  spine ;  lower 
back  toward  the  sacral  notches. 

Stroking  is  always  done  in  the  direction  of  the  lym- 


54  PHYSICAL  RECONSTRUCTION 

phatio  and  venous  flow,  the  only  exception  being  to  re- 
move secretions  from  an  open  wound. 

MECHANICS  AND   PHYSIOLOGICAL  EFFECT 

Effleurage  or  StroMng.  Stroking  is  done  with  one  or 
both  hands  or  any  part  thereof  simultaneously,  alter- 
nately or  with  one  only  and  with  varying  degrees  of 
force,  rapidity  and  duration,  depending  upon  the  part 
massaged  and  the  purpose  in  view.  The  object  is  to  in- 
fluence the  blood  and  lymphatic  circulations.  The  super- 
ficial circulation  is  always  affected,  the  deeper  only  by 
added  pressure.  The  direction  is  always  toward  the 
heart  with  the  exception  noted  above. 

The  skin  is  mildly  stimulated,  but  this  effect  is  les- 
sened with  the  use  of  lubrication. 

Sensory  nerve  endings  in  the  skin  are  stimulated  by 
stroking  and  the  sum  total  of  the  effect  depends  upon 
concentration  of  the  nerve  endings  in  the  part,  the  amount 
of  surface  covered,  and  the  number  of  strokes  used. 
Since  stimulation  depends  upon  variation,  and  nerve  end- 
ings soon  become  dulled  to  the  same  type  and  degree  of 
stimulus,  repeated  light  stroking  is  in  its  sum  total  ef- 
fect soothing. 

The  circulation  may  be  greatly  modified  by  stroking. 
No  measurable  effect  can  be  procured  on  the  arterial  flow. 
Capillaries  are  dilated  by  strong  stroking  and  contracted 
by  light  stroking.  Venous  circulation  can  be  markedly  im- 
proved. The  stroking  should  be  deep  enough  to  compress 
the  vein,  more  rapid  than  the  venous  circulation,  which 


Fig.  19.    Massage.    Tapotement  or  Hacking  of  Muscle. 

Fig.  20.     (A)  Posterior  Half  Cast  to  Prevent  Foot  Drop.  (See  Fig.  58 

for  X-Rav.> 


MASSAGE  57 

is  not  more  than  five  inches  a  second,  and  long  enongh  to 
extend  over  the  next  proximal  valve,  which  would  be  from 
six  to  eight  inches.  The  lymphatic  flow  will  be  aided  by 
slow,  deep  stroking,  especially  over  the  lymph  glands. 

The  muscle  can  be  directly  relieved  in  fatigue  through 
the  removal  of  waste  products  by  deep  stroking. 

Glands  can  be  stmiulated  by  the  indirect  effect  of  cir- 
culatory changes  in  the  skin. 

In  such  bones  as  the  tibia  the  periosteal  circulation 
and  nutrition  can  be  aided. 

Several  writers  have  called  attention  to  the  different 
effects  produced  on  muscle  tissue  by  the  different  types 
of  massage.  They  consider  light  stroking  to  be  both 
soothing  and  relaxing  and  therefore  indicated  in  spastic 
contracture.  Others  do  not  massage  spastic  muscle  at 
all. 

Petrissage.  Pinching,  Kneading.  This  type  of  mas- 
sage is  used  mainly  for  its  effect  on  muscle  tissue.  The 
amount  of  tissue  grasped  would  then  depend  upon  the 
part  being  massaged.  Fine  pinching  is  done  between  the 
thumb  and  first  finger.  Coarser  pinching  between  the 
thumb  and  the  side  of  the  second  phalanx  of  the  first 
finger,  or  the  thumb  opposed  by  the  tips  of  all  the  fingers, 
is  good  on  a  flat  surface,  such  as  the  back ;  to  this  twist- 
ing may  be  added  for  more  vigorous  effect.  The  hands 
may  be  used  effectively  close  together  and  alternately, 
one  pinching  while  the  other  is  re-grasping. 

On  the  extremities  the  hands  may  be  used  on  opposing 
sides,  completely  grasping  the  various  muscle  groups. 
The  direction  of  the  pinching  should  be  at  right  angles 


58  PHYSICAL  RECONSTRUCTION 

to  the  muscle  fibers.  On  the  abdominal  wall,  where  we 
are  unable  to  obtain  selective  action  on  the  different 
layers  of  muscle,  it  is  well  to  knead  in  concentric  circles. 

Pinching  the  muscle  fibers  brings  about  a  partial  con- 
traction of  those  having  their  nerve  supply  intact.  Some 
orthopedists  believe  a  beneficial  or  a  stimulating  effect 
may  follow  even  where  we  find  that  the  nerve  supply 
is  entirely  lacking.  It  is  easier  to  obtain  a  partial  con- 
traction of  a  large  number  of  fibers,  or  a  complete  con- 
traction of  a  few  by  this  means  than  by  the  use  of  elec- 
tricity. Since  only  the  stimulated  part  of  the  muscle  re- 
acts, we  may  by  this  means  keep  up  the  tone  and  health 
of  muscles  in  the  immediate  neighborhood  of  inflamed 
joints,  yet  at  no  time  cause  an  undesired  movement  of 
the  joint.  For  this  partial  effect  the  different  nerve  sup- 
plies and  the  several  heads  of  the  various  muscles  must  be 
kept  in  mind.  A  beginner  should  early  learn  to  differen- 
tiate in  infantile  paralysis  the  thick,  fat  and  connective 
tissue  layer  which  so  often  overlies  the  muscle  and  upon 
which,  without  due  care,  the  petrissage  may  be  directed 
from  the  muscle  itself.  ^ 

Tapotement.  Hacking,  slapping,  vibrating.  This  pro- 
cedure is  aimed  at  the  skin  and  the  muscles. 

Skin  slapping  should  be  done  with  light,  fast,  alternate 
strokes.  The  wrist  should  be  relaxed,  each  hand  instant- 
ly rebounding  from  the  skin.  Superficial  blood  vessels 
and  later  the  deeper  vessels  are  quickly  dilated  in  this 
manner. 

Over  groups  of  muscle  the  strokes  are  made  alternately 
with  the  ulnar  sides  of  the  hands.    Here,  too,  the  wrists 


Fig.  21.     High  Explosive  Wound  of  Left  Hand. 

Loss  of  third  and  fourth  fingers  and  part  of  hand.    Function  good  following 
exercise  and  massage.     (X-ray  Fig.  22.) 

Fig.  22.    Loss  of  3rd  and  4th  Metacarpals. 


MASSAGE  61 

should  remain  relaxed,  the  hand  nearly  open,  the  fingers 
slightly  separated.  In  this  manner  the  fourth  finger 
strikes  the  part  first,  the  others  following  in  turn.  For 
harder  striking,  to  relax  a  knotted  muscle,  for  instance, 
the  hand  may  be  held  rigidly  extended  and  the  strokes 
given  more  heavily,  only  the  ulnar  side  of  the  hand  and 
little  finger  striking  the  part. 

Another  method  is  by  the  use  of  the  partially  clenched 
hand,  palm  down,  striking  flat  with  the  second  phalanges 
of  the  fingers. 

Vibrating  can  be  done  by  keeping  the  finger  tip  or 
other  parts  of  the  hand  in  contact  with  the  patient,  the 
wrist  relaxed,  and  performing  a  shaking  motion  of  the 
whole  arm. 

The  stimulation  resulting  from  this  method  depends 
upon  the  number  and  force  of  the  strokes  and  the  amount 
of  surface  covered. 

Frictions.  Frictions  are  seldom  used  except  on  ad- 
ventitious tissue  in  a  number  of  pathological  conditions. 
The  breaking  up  of  scars  and  adhesions  forms  an  im- 
portant part  of  its  usefulness.  We  generally  approach 
such  tissue  by  concentric  circles  starting  well  out  at  the 
periphery.  Frictions  of  the  spine  are  sometimes  used 
to  stimulate  the  nerve  roots.  This  manipulation  is  also 
valuable  in  the  reduction  of  callus. 

THERAPEUTIC   USES  AND   CONTRAINDICATIONS 

Skin.  Where  the  skin  is  dry,  harsh  and  cold,  slapping 
will  dilate  peripheral  capillaries,  warm  the  skin  and  in- 
duce perspiration.     Oold,  clammy,  moist  skin  can  be 


62  PHYSICAL  RECONSTRUCTION 

aided  by  frequent  light  stroking  centrally  above  the  part 
to  aid  the  venous  circulation. 

Glands.  Inactivity  of  the  sebaceous  glands,  followed 
by  the  formation  of  blackheads  and  pimples,  often  oc- 
curs where  the  skin  is  normally  rather  immobile.  Mas- 
sage will  improve  the  circulation,  mechanically  squeeze 
out  the  inspissated  secretion  and  restore  normal  gland 
activity. 

Dandruff  is  the  result  of  hypersecretion  of  these 
glands  in  the  scalp.  The  oil  not  being  fluid  enough,  in- 
stead of  supplying  the  hair  it  collects  in  layers  around  the 
gland  openings  and  flakes  off.  The  hair  not  being  prop- 
erly oiled,  tends  to  dry  and  break  off  or  split.  Massage 
of  the  scalp  will  stimulate  gland  activity  and  the  return 
of  the  sebaceum  to  its  normal  fluidity. 

After  chronic  inflammation  of  the  skin,  for  instance, 
as  caused  by  boils  or  carbuncles,  scar  tissue  may  be  re- 
duced. 

Scars.  It  must  be  remembered  that  scars  are  com- 
posed of  connective  tissues  only  and  contain  no  sweat  or 
sebaceous  glands  and  no  touch,  pain,  or  heat  corpuscles 
and  are  the  result  of  wounds  not  healing  by  first  inten- 
tion. Frictions  over  and  around  scars  will  reduce  the 
amount  of  tissue  in  duration  and  the  size  of  the  scar 
itself.    Massage  will  prevent  tissue  contraction. 

Atrophy.  This  condition  is  commonly  seen  after  the 
wearing  of  casts  or  on  the  soles  of  the  feet  after  pro- 
longed rest  in  bed.  Massage  is  extremely  useful  here 
in  restoring  skin  function  and  hardening  the  soles  of  the 
feet  preparatory  to  walking. 


MASSAGE  63 

Contraindications.  1.  Hypersensitivity  of  the  touch 
corpuscles,  which  may,  however,  reflect  the  same  state 
of  the  mind,  contraindicates  massage.  Parts  covered 
by  hair  must  be  well  lubricated  or  shaved.  This  shav- 
ing does  not  stimulate  the  growth  of  hair  as  much  as  does 
the  repeated  irritation  caused  by  the  pulling  of  the  mas- 
sage itself. 

2.  Pimples  or  skin  infection  are  not  massaged.  In  case 
it  is  necessary  to  stroke  a  skin  covered  with  blackheads 
and  pimples,  clean  thoroughly  before  and  again  after 
the  treatment  with  alcohol  or  soap  and  water. 

CAEDIO-VASCXJLAB   SYSTEM 

The  Heart.  The  heart  can  at  times  be  stimulated  by 
tapotement  directly  over  its  location,  or  this  procedure 
over  the  stomach  may  greatly  relieve  cardiac  embarrass- 
ment caused  by  gas  formation  there. 

Pericarditis.  Here  the  heart  laboring  under  mechani- 
cal difficulties  which  retard  its  action  can  be  relieved  by 
stroking  of  the  extremities,  thus  removing  some  of  its 
normal  work. 

Myocarditis.  In  the  same  way  a  weakened  or  inflamed 
heart  muscle  can  be  relieved  of  some  of  its  load.  This 
very  obvious  fact  in  therapeutic  indications  for  massage 
has  been  almost  entirely  overlooked  by  the  general  pro- 
fession. Graded  muscular  exercise  should,  if  possible, 
be  given  in  conjunction  with  massage. 

Endocarditis.  This  condition  can  be  aided  in  the  same 
way  and,  since  cardiac  dilatation  is  sometimes  due  to  back 


64  PHYSICAL  RECONSTRUCTION 

pressure  from  the  venous  system,  this  mechanical  aid 
should  never  be  withheld. 

Contraindications.  Tapotement  and  the  more  vigorous 
types  of  massage  may  often  be  useless,  but  gentle  strok- 
ing in  the  direction  of  the  venous  return  will  always  aid 
a  heart  working  under  a  handicap.  Acute  endocarditis 
and  purulent  myo-  or  pericarditis  and  angina  pectoris 
contraindicate  massage. 

Veins.  Dilatation  of  the  veins  may  be  treated  by  ele- 
vation and  stroking,  which  may,  especially  in  the  veins 
of  the  lower  leg,  prevent  them  from  becoming  varicose. 
Varicose  veins  cause  a  great  deal  of  extra  work  to  be 
thrown  on  the  heart  through  venous  stagnation.  Massage 
by  gentle  stroking  above  and  below.  When  the  dilata- 
tion is  not  marked  or  any  sign  of  ulceration  present, 
slow,  gentle  stroking  may  be  done  directly  over  them. 

Phlebitis.  Here  the  walls  thicken,  a  sign  of  inflamma- 
tion in  the  vein,  which  may  greatly  enlarge,  become  ad- 
herent to  the  surrounding  tissue  or  break  down  and  ul- 
cerate. Later  joint  contractures  may  form  in  the  knee 
or  elbow.  Elevation  and  rest  should  be  given  in  the 
active  stage.  Later  on  gentle  frictions  and  stroking  at 
the  sides  over  the  non-inflamed  veins  and  above  and  below 
the  inflamed  part,  to  aid  in  removing  the  swelling,  is  of 
value.  Contraindications.  In  varicose  veins  any  pro- 
cedure except  stroking  is  to  be  avoided  and  even  this  is 
not  done  when  the  walls  are  thin  or  ulcers  have  formed. 

In  phlebitis,  during  the  active  stage,  or  at  any  time  di- 
rectly over  the  vein,  avoid  massage  for  fear  of  freeing 
a  thrombus. 


MASSAGE  65 

Lymphatics.  Dilated  lymph  capillaries  and  spaces  may 
be  massaged  with  stroking  and  deep  pressure  centrally, 
with  light  friction  added  over  the  lymph  nodes.  Eleva- 
tion is  helpful.  Contraindications.  Active  inflammation 
contraindicates  all  direct  massage. 

Arteries.  No  disease  of  the  larger  arteries  is  amenable 
to  massage  treatment.  The  compensatory  circulation 
may  be  improved  in  obliterating  endarteritis.  Arterio- 
sclerosis usually  begins  in  the  capillaries  and  arterioles 
in  the  distal  extremities,  the  left  leg  being  often  the  first 
point  of  onset.  The  X-ray  may  show  this  condition.  Tor- 
tuous temporal  arteries,  arcus  senilis,  palpation  of  the 
radial  artery  and  high  blood  pressure  are  other  means 
of  determining  its  presence.  A  general  massage  con- 
tinued for  years  and  well  done  on  the  extremities  and 
the  veins  of  the  surface  will  often  arrest  the  progress  of 
this  disease  and  may  give  partial  recovery.  The  mental 
attitude  of  these  patients  is  greatly  helped  and  this  is 
a  most  desirable  and  important  element  in  the  treatment. 
Contraindications.  Tapotement,  when  the  condition  is 
at  all  advanced,  and  in  aneurism,  should  not  be  used. 

MUSCULAB   SYSTEM 

Myositis.  Muscle  soreness  follows  the  insufficient  re- 
moval of  fatigue  products.  Stroke  centrally  above  the 
muscle  to  open  up  the  lymph  channels  and  then  stroke 
over  the  muscle. 

Knotted  muscle,  which  occurs  in  athletes,  especially 
track,  after  severe  exertion,  is  the  next  stage  of  the  same 
process,  but  includes  as  a  rule  the  tearing  of  a  few  fibers 


66  PHYSICAL  RECONSTRUCTION 

with  some  serous  exudate  into  the  muscle  tissue.  Pro- 
ceed as  in  muscle  soreness  just  described  but  the  stroking 
of  the  muscle  itself  should  be  deeper  and  of  greater  dura- 
tion with  some  friction  added. 

Muscle  Bruise.  Here,  in  addition,  occurs  hemorrhage 
into  the  muscle  with  discoloration.  If  treated  at  once, 
it  is  dealt  with  as  in  knotted  muscle.  Later  the  fibrin 
glues  the  muscle  fibers  together  and  deep  frictions  must 
be  used  to  break  it  up.  Work  in  concentric  circles.  If 
neglected  for  some  time  the  blood  clot  may  become  or- 
ganized and  a  great  deal  of  exertion  must  be  put  into  the 
massage  and  a  longer  time  given  to  the  treatment.  Vig- 
orous tapotement  should  be  added.  Occasionally  it  may 
be  necessary  to  make  the  muscle  '* black  and  blue"  again 
by  this  means  before  the  organized  mass  can  be  broken 
up  and  the  free  play  of  the  bundles  restored. 

Torn  Muscle.  This  is  usually  associated  with  severe 
bruising  and  is  followed  by  true  scar  formation  within 
the  muscle.  This  scar  must  if  possible  be  reduced  and 
broken  up  in  the  same  manner  as  for  a  bruise,  but  the 
part  should  be  immobilized  between  the  treatments.  The 
bandaging  should  start  above  and  below  and  work  to- 
ward the  tear,  thus  keeping  the  fibers  approximated.  It 
is  evident  that  tight  bandaging  started  directly  over  the 
lesion  would  force  the  fibers  apart  and  increase  the 
amount  of  scar  formation. 

''Charley  Horse'*  is  a  subperiosteal  hematoma  which 
follows  deep  bruising  that  involves  the  periosteum,  tear- 
ing some  of  its  blood  vessels.  Frictions  and  stroking  will 
prevent  organization  and  hasten  reabsorption.    This  is 


MASSAGE  67 

a  common  football  injury  of  the  front  of  the  thigh  and 
its  presence  is  indicated  when,  with  knee  raised  forward, 
the  patient  is  unable  to  extend  the  leg.  Contraindica- 
tions: Purulent  myositis,  trichinosis,  and  muscle  wounds 
should  not  be  massaged. 

Atrophic  Muscle.  The  commonest  condition  we  deal 
with  here  is  infantile  paralysis.  The  lesion  is  primarily 
in  the  motor  and  trophic  nerves ;  occasionally  the  sensory 
are  involved.  While  massage  is  aimed  at  aiding  nutrition 
and  stimulating  any  muscle  cells  and  nerve  endings  that 
may  be  alive,  we  must  remember  in  children  how  de- 
pendent we  are  for  growth  upon  contact  stimuli.  These 
are  usually  lacking,  but  can  to  some  extent  be  supplied  by 
massage.  Slapping  and  light  tapotement  with  open  fin- 
gers are  useful,  and  fine  pinching,  which  must  penetrate 
the  layer  of  fat  and  connective  tissue  and  be  directed  on 
the  muscle  fibers,  is  of  great  value.  The  intrinsic  power 
of  all  muscle  tissue  to  contract  is  thus  stimulated  even  in 
the  absence  of  motor  impulses.  Contraindications:  In 
the  active  stage  of  infantile  paralysis  no  massage  should 
be  used,  and  in  advanced  atrophy  of  old  age  or  convales- 
cence only  stroking  is  indicated. 

Spastic  Muscle.  Stimulating  massage  of  the  physio- 
logical opponent  is  good  and  on  the  muscle  itself  gentle 
stroking,  which  is  now  believed  to  be  relaxing,  aids  the 
condition.  Some  authors,  however,  call  all  massage  oon- 
traindicated  in  spastic  muscle. 

Sarcolemma  or  Muscle  Sheath  Inflammation.  This 
structure  is  often  inflamed  in  places  where  a  large  number 
of  muscles  lie  close  together  and  considerable  friction  de- 


68  PHYSICAL  RECONSTRUCTION 

velops  during  their  overuse,  as  in  the  neck,  forearm  and 
calf.  The  ' '  spike  soreness ' '  of  track  men  is  of  this  type 
in  the  opinion  of  some  writers ;  others  class  it  as  a  neu- 
ritis. Rest,  baking  and  elevation  are  invaluable  adjuncts 
to  massage  stroking.  Try  to  get  between  the  muscles 
with  the  tips  of  the  fingers.  In  chronic  cases  where  there 
may  be  organized  deposits,  use  deep  friction  followed  by 
stroking. 

Tendon  Sheath  Inflammation.  Tendons  themselves  sel- 
dom are  inflamed  or  injured.  The  sheath  acts  as  a  deli- 
cate insulation  within  which  the  tendon  moves.  This 
movement  requires  constant  lubrication  by  a  fluid  se- 
creted by  cells  in  the  inner  layer  of  the  sheath.  Overuse 
will  exhaust  this  fluid  and  set  up  an  inflammation  (teno- 
synovitis). Overproduction  of  fluid  then  takes  place, 
distending  the  sheath  with  pressure  on  adjoining  struc- 
tures. Fibrin  may  coagulate  within  the  sheath  and  form 
a  painful,  semi-solid  swelling.  In  the  vn:ist  and  ankle  the 
annular  ligaments  may  partially  shut  off  a  portion  of  the 
tendon  sheath  and,  aided  by  gravity,  hasten  coagulation. 
Occasionally  the  fluid  may  enter  a  joint  cavity  and  float 
the  bones  apart  with  a  tendency  to  sprain  and  dislocate. 
Any  mechanical  interference  in  the  absorption  of  the  ex- 
cess fluid,  unless  it  be  a  snugly  fitting  bandage  from  the 
extreme  distal  part  completely  over  the  entire  swelling, 
may  be  injurious ;  hence  wrist  and  ankle  supporters  often 
do  more  harm  than  good.  The  tight  lacing  of  high  shoes 
is  a  common  cause  or  an  aggravation  of  this  condition. 

Treat  by  heat,  rest,  removal  of  constrictions  and  ef- 
fleurage,  with  frictions  if  any  coagulation  is  present. 


MASSAGE  69 

Contraindications.    Wounds  and  pumlent  inflammations 
should  not  be  massaged. 

BONES 

Periostevm.  Chronic  periostitis  may  be  greatly  aided 
by  deep  stroking,  especially  in  bones,  like  the  tibia,  which 
are  practically  subcutaneous. 

Scar  formation  following  tears  may  be  lessened  by 
friction  and  stroking. 

Hemorrhage  beneath  the  periosteum  has  been  de- 
scribed under  diseases  of  the  muscle. 

Fractures.  The  large  callus  that  usually  follows  frac- 
ture repair  may  be  reduced  by  frictions.  These  calluses 
may  include  some  of  the  soft  parts  which  must  first  be 
liberated.  Deep  frictions  working  circularly  from  the 
periphery  to  the  center  are  best. 

The  action  of  the  muscles  may  be  greatly  hindered  by 
having  to  work  over  such  an  enlargement.  Occasionally 
there  may  be  great  pain  and  discomfort  from  this  condi- 
tion. Even  a  small  callus  may  cause  trouble  if  situated 
near  the  joint.  Fractures  involving  joints,  which  have 
been  so  common  in  the  European  war,  have  proven  the 
indispensability  of  massage  treatment  to  reduce  callus 
and  to  break  up  foreign  bodies  and  adhesions.  Callus 
formation  interfering  with  joint  movement  may  be  too 
soft  to  be  disclosed  by  the  X-ray  and  yet  demands  atten- 
tion. 

Faulty  Metabolism.  Such  conditions  as  rickets  may 
be  greatly  aided  by  massage  aimed  at  the  circulation. 
General  body  massage  is  often  indicated  and  improved 


70  PHYSICAL  RECONSTRUCTION 

nutrition  of  the  bones  leads  to  increased  formation  of 
red  blood  corpuscles.  Contraindications.  Immediately 
after  fracture  and  in  acute  inflammations,  osteitis,  os- 
teomyelitis and  periostitis,  massage  is  not  used. 

JOINTS 

Dislocations.  Gentle  friction  and  stroking  will  aid  the 
healing  of  the  torn  ligaments.  In  certain  joints,  for  ex- 
ample, the  shoulder,  there  is  a  tendency  for  the  disloca- 
tion to  recur  and  here  the  treatment  should  be  delayed. 

Sprains.  These  should  be  massaged  at  once  in  spite 
of  pain.  Deep  strokes  and  frictions  aid  in  the  removal  of 
extravasated  blood  and  help  to  prevent  its  clotting.  If 
the  case  is  not  seen  until  the  clot  has  organized  it  must 
be  broken  up  by  deep  frictions  followed  by  stroking.  If 
this  is  not  done  the  ligaments  heal  over  the  clot,  which, 
when  it  is  finally  absorbed,  leaves  the  ligaments  elongated 
and  relaxed  with  a  tendency  to  frequent  recurrence.  As 
I  have  before  emphasized,  there  is  no  treatment  available 
superior  to  this,  coupled  with  a  support  to  prevent  re- 
sprain. 

Synovial  membrane  is  always  involved  in  joint  injuries. 
There  is  an  increased  secretion  of  synovia  by  means  of 
which  nature  attempts  to  float  apart  the  two  inflamed 
surfaces.  This  results  in  lateral  insecurity  of  the  joint 
and  this  is  where  support  is  indicated.  In  the  case  of  the 
knee  a  posterior  splint,  which  is  commonly  used,  is  not 
the  preferred  treatment  but  a  lateral  hinged  brace,  which 
prevents  twisting  and  lateral  strain,  but  allows  normal 
hinge  movement,  is  indicated.    Because  of  the  relatively 


MASSAGE  71 

poor  blood  supply,  such  injuries  heal  rather  slowly,  but 
a  week  should  suffice  in  the  ordinary  case.  When  repair 
is  delayed  much  beyond  this  time  suspicion  of  the  pres- 
ence of  toxins  should  lead  to  careful  examination  of  the 
teeth,  gastro-intestinal  tract,  etc.  Baking  and  counter- 
irritation  are  of  value.  Massage  should  consist  of  ef- 
fleurage  above  and  over  the  sprain.  In  the  chronic  or 
subacute  stage  the  excess  of  fluid  is  absorbed,  leaving 
a  gelatinous  residue  containing  fibrin,  which  tends  to 
coagulate.  Hard  frictions,  getting  as  deeply  inta  the 
joint  as  possible,  are  then  indicated.  If  coagulation  has 
taken  place,  small  particles  may  be  broken  off  and  become 
loose  in  the  joint.  In  the  knee  the  so-called  **rice  kernels" 
are  of  this  type.  Here  the  joint  should  be  fully  flexed  to 
open  it  up  and  moved  several  times  during  the  treat- 
ment to  shift  the  particles  under  the  fingers.  The  next 
stage  in  untreated  cases,  or  in  repeated  sprain,  is  a  thick- 
ening of  the  synovial  membrane  which  may  not  be  ap- 
parent for  two  or  three  weeks.  Here,  too,  the  joint  be- 
comes insecure  with  tendency  to  subluxation  and  re- 
injury. The  synovial  membrane  becomes  thick  and 
spongy  and  rolls  between  the  bones  like  dough  before  a 
rolling-pin  and  a  fold  or  crease  in  front  or  rear  may 
limit  joint  movement.  Normal  movement,  well  protect- 
ed, still  tends  toward  cure,  but  as  a  rule  heat  and  mas- 
sage must  be  continued  for  months  before  permanent  re- 
covery takes  place.  Contraindications.  Infective  in- 
flammations, toxic  inflammations  when  most  acute,  and 
dislocation  while  unreduced  should  not  be  massaged. 


72  PHYSICAL  RECONSTRUCTION 

NERVOUS  SYSTEM 

Brain  Diseases.  The  quieting  effect  of  stroking,  espe- 
cially of  the  back,  may  be  of  service  in  mild  states  of 
mental  agitation.  After  a  prolonged  agitation,  sys- 
tem exhaustion  may  be  lessened  by  complete  massage 
treatments.  The  persistent  chronic  constipation  asso- 
ciated with  many  of  these  disorders  may  be  relieved  by 
abdominal  massage  of  the  type  to  be  described. 

"Softening  of  the  brain"  resulting  from  faulty  circu- 
lation in  localized  areas  cannot  directly  be  affected. 
When  it  involves  motor  areas,  however,  the  affected  mus- 
cle should  be  treated  by  reeducational  gymnastics  and 
"muscle  massage." 

Apoplexy.  Downward  stroking  of  the  veins  of  the 
neck  relieves  congestion.  Treat  the  paralyzed  muscle  by 
"muscle  massage."  This  has  not  only  a  distinct  local 
beneficial  effect  but  a  pronounced  sedative  influence  upon 
the  patient's  mental  condition.  Contraindications.  In 
acute  inflammations  of  the  brain,  meningitis  and  hyper- 
susceptibility  massage  should  not  be  used. 

SPINAL   DISEASES 

Injuries.  The  spine  cannot  be  directly  stimulated  be- 
cause of  its  location. 

Infantile  Paralysis.  Stroking  of  the  back  may  be 
beneficial  in  the  subacute  stage.  Local  massage  of  the 
affected  muscle  should  not  be  begun  until  tenderness  has 
entirely  disappeared,  but  thereafter  it  must  be  continued 


MASSAGE  73 

until  recovery  or  for  a  number  of  years.  Contraindica- 
tions.   The  acute  stage  contraindicates  massage. 

Functional  Diseases.  Improvement  in  diagnosis  and 
recent  researches  are  bringing  us  more  and  more  to  the 
point  of  view  that  pure  functional  neuroses  are  extremely 
rare,  and  that  there  is  usually  an  organic  or  functional 
lesion  somewhere.  This  should  be  diligently  sought  and 
if  found  removed. 

Neurasthenia.  The  nervous  and  bodily  weakness  ac- 
companying this  condition  is  more  efficiently  treated  by 
regular  and  complete  massage  than  by  almost  any  other 
method  at  our  command.  Both  mentally  and  physically 
great  benefit  is  usually  obtained.  The  muscles  are  kept 
in  good  health  and  tone  without  the  expenditure  on  the 
part  of  the  patient  of  the  energy  which  exercise  would 
require.  Later  on  massage  should  be  supplemented  by 
graded  exercise. 

Hysteria.  General  massage  is  indicated  here  when 
possible  for  its  general  tonic  effect.  Contraindications. 
Violent  hysteria  should  not  be  treated  by  massage. 

Peripheral  Nerves.  Thickening  of  the  nerve  sheath 
following  injury  can  sometimes  be  relieved  by  light  strok- 
ing. The  nerves  are  often  caught  in  scars  following  frac- 
tures or  extensive  tissue  destruction.  They  must  be 
loosened  up  and  relieved  from  the  pressure  by  passive 
movements,  friction  and  stroking. 

Neuralgia.  This  is  a  symptom,  not  a  disease.  Mas- 
sage may  help  to  remove  the  cause.  It  is  contraindicated 
on  the  affected  part. 

Neuritis.    This  is  commonly  a  result  of  some  constitu- 


74  PHYSICAL  RECONSTRUCTION 

tional  poison  and  the  massage  is  directed  toward  helping- 
the  body  eliminate  the  causative  agent.  The  muscular 
atrophy  which  usually  accompanies  severe  neuritis  can 
be  retarded.  Contraindications.  Massage  over  the  af- 
fected nerve  is  contraindicated. 

ABDOMINAL  VISCERA 

Stomach.  Vigorous  tapotement  directly  over  the 
stomach  will  often  assist  in  the  elimination  of  gas  which 
may,  beside  causing  local  distress,  be  embarrassing  the 
action  of  the  heart. 

Intestines.  Chronic  Constipation.  This  is  one  of  the 
most  common  distressing  and  truly  important  conditions 
with  which  we  are  concerned.  Among  the  common  causes 
are  enteroptosis  with  stretched  mesentery,  partially  oc- 
cluding the  blood  vessels  and  resulting  in  atonic  muscula- 
ture. The  mechanical  stimulation  to  proper  peristalsis 
is  dependent  upon  the  presence  of  a  fairly  large  bolus 
within  the  intestine  and  then  a  period  of  rest.  This  means 
regular  meals  and  not  the  constant  nagging  of  small 
amounts  of  contents  without  rest  periods.  It  also  re- 
quires that  we  eat  a  reasonable  amount  of  indigestible 
residue,  largely  cellulose,  to  maintain  the  required  bulk. 
Lack  of  normal  secretion  within  the  gastro-intestinal 
tract,  adhesions  and  lack  of  the  formation  of  regular 
habits  of  attempt  at  evacuation  may  also  be  important 
causes.  Long  dependence  on  drugging  is  unwise.  We 
must  first  not  only  eliminate,  if  possible,  the  cause  but 
bring  to  our  assistance  every  factor  that  will  aid  in  the 
return  of  the  normal  function.    Bodily  exercise  and  espe- 


MASSAGE  75 

cially  abdominal  exercise  of  the  type  outlined  for  lordosis 
is  very  eflScacious.  By  massage  we  may  increase  the  tone 
of  the  abdominal  muscles,  thereby  lessening  ptosis,  and 
in  most  cases  we  may  directly  stimulate  intestinal  mus- 
cle coats.  Deep  pressure  with  the  heel  of  the  hand  or 
the  fist  should  begin  over  the  cecum  and  follow  the  course 
of  the  large  intestine.  Circular  stroking  should  follow 
the  same  course.  Deep  frictions  should  be  thorough  at 
the  hepatic  and  splenic  flexure,  where  deep  stroking  from 
back  to  front  between  the  lower  ribs  and  the  pelvis  should 
be  vigorously  applied.  On  the  left  side  the  ulnar  sur- 
face of  the  hand  in  many  cases  may  follow  the  sigmoid 
flexure  for  quite  a  distance  downward  and  forward. 

Liver.  Tapotement  over  the  ribs  covering  the  liver, 
circular  frictions  over  its  free  edge  and  gentle  depression 
of  the  movable  ribs  will  stimulate  hepatic  activity. 

Pancreas,  kidneys  and  bladder  are  not  treated  by  mas- 
sage. 

Hernia  may  be  aided  indirectly  by  bettering  the  nutri- 
tion of  the  abdominal  wall  muscles,  especially  where  a 
truss  is  worn.  Contraindications.  Any  abdominal  ten- 
derness, pregnancy,  and  all  acute  infectious  diseases  con- 
traindicate  massage. 

Scalp.  The  scalp  is  often  rather  tight  and  its  circula- 
tion somewhat  impaired.  It  can  be  loosened  by  finger 
tip  friction  with  considerable  benefit  to  the  circulation 
and  the  growth  of  hair. 

Limb  Stumps.  In  all  its  range  of  usefulness  massage 
gives  no  more  gratifying  results  than  in  the  preparation 
of  stumps  for  artificial  limbs.   In  a  great  number  of  cases 


76  PHYSICAL  EECONSTRUCTION 

at  the  Walter  Eeed  Hospital  in  Washington  careful  mas- 
sage has  worked  wonders. 

During  the  war  many  of  the  stumps  were,  under  stress 
of  circumstances,  operated  on  in  such  a  way  as  to  make 
it  extremely  difficult  to  prepare  them  for  weight  bear- 
ing. The  chief  pressure  from  an  artificial  limb  is  lateral, 
but  the  soft  tissue  must  be  drawn  down  to  form  a  cushion 
over  the  end  of  the  bone.  Massage  should  be  begun  at 
the  earliest  possible  moment  regardless  of  whether  or 
not  the  wound  is  healed.  If  effleurage  is  used  great  care 
should  be  taken  to  prevent  drawing  up  of  the  muscles. 
The  stroking  should  be  mostly  downward.  Vibration 
and  friction  are  used  concentrically  from  above  down- 
ward, loosening  the  scar  and  working  to  the  very  edge 
of  the  new  formed  tissue  over  and  around  the  end  of  the 
bone.  Where  this  technique  is  followed  very  few  of  the 
blue,  cold  stumps,  such  as  were  common  earlier  in  the 
war,  result  and  the  whirl  bath  for  theirrelief  is  unneces- 
sary. 

Simmmry.  I  would  again  emphasize  the  fact  that  it 
is  necessary  to  know  thoroughly  anatomy  and  physiology 
and  the  reaction  of  the  various  tissues  to  strain,  injury, 
under-nourishment,  etc.  With  this  knowledge,  and  a  gen- 
eral idea  of  the  technique  of  the  main  movements,  the 
masseur  is  at  liberty  to  develop  his  own  special  technique 
and  method  of  procedure.  One  so  equipped  is  in  a  far 
better  position  to  perform  successful  and  helpful  work 
than  one  working  merely  from  the  mechanical  standpoint, 
be  he  ever  so  efficient  in  any  given  system  or  school  of 
massage. 


It  paEECS  tiire  pieafaritly 


Fig.  23.     Basket-m.\ki.ng. 

Can  be  begun  while  the  patient  is  still  hediiddtn. 
and  has  therapeutic  value  in  hand  and  wrist  injuries. 

Fig.  24.    Telegraphy. 

Instruction  begins  at  the  bedside  and  is  carried  on  through  the  shop  to  fold 
work. 


i'lU.    2.").        ('lav    AIoDKl.lXG. 

One  of  the  most  valuable  therapeutic  measures  for  joint  mobihty  in  the 
fingers  and  hand.  It  can  be  used  very  early  in  cases  where  more  complicated 
work  ia  impossible. 

Fia.  26.    Chair  Caning. 

A  trade  of  great  vocational  value  with  many  varied  movements  of  the  hand 
and  arm  which  aid  in  restoring  function. 

Fig.  27.     Wood  Toy  Making. 

Ps3rchologically  most  patients  become  like  children  for  a  time.  They  are  then 
easily  interested  m  toy  making.  Later  this  interest  and  incentive  to  work  is 
transferred  to  other  things. 


Chapteb  IV" 

VOCATIONAL  THERAPY 

This  branch  of  physical  reconstruction  is  growing  most 
rapidly  in  its  breadth  of  application  to  war  injuries.  The 
problems  met  and  overcome  so  successfully  are  those 
which  must  in  the  future  be  met  by  the  surgeon  in  civil 
practice.  The  work  done  and  the  lessons  learned  will  be 
of  the  greatest  value  to  the  compensation  insurance  com- 
panies whose  interest  in  the  men  crippled  in  industrial 
life  closely  parallels  the  economic  interest  of  the  govern- 
ment in  the  soldiers.  Insurance  companies  have  of  late 
recognized  that  treatment  of  the  insured  by  physiotherapy 
in  many  cases  is  a  paying  investment,  the  men  being 
returned  to  partial  or  complete  eflBciency  at  a  much  earlier 
date  than  would  otherwise  have  been  possible.  It  is  cer- 
tain that  vocational  therapy  will  in  the  future  play  an 
increasing  role  in  the  treatment  of  convalescent  em- 
ployees. The  larger  manufacturing  concerns  which  take 
care  of  their  own  compensation  cases  would  in  like  man- 
ner gain  much  from  a  careful  consideration  of  these  mod- 
em methods  of  treatment,  which  have  proven  their  effi- 
ciency in  far  too  large  a  group  of  cases  to  ever  be  con- 
sidered fads.  The  facts  are  that  we  have  as  yet  ex- 
hausted but  a  small  part  of  the  possibilities  which  these 

methods  of  treatment  hold  forth. 

79 


80  PHYSICAL  RECONSTRUCTION 

Specifically,  the  objects  of  vocational  therapy  are  thera- 
peutic, economic,  occupational  and  to  improve  morale. 
In  the  early  treatment  of  men  in  the  army  the  therapeu- 
tic indications  control  to  a  large  extent  the  type  and 
amount,  or  dosage,  of  work  outlined  for  a  patient.  For 
example,  a  man  with  scar  tissue  contracture  or  fibrous 
adhesions  in  the  elbow  joint,  allowing  only  limited  motion 
in  semi-flexion,  may  be  put  at  planing  in  the  carpenter 
shop.  This  treatment  is  given  the  man  as  far  as  possible 
on  the  prescription  of  the  surgeon,  as  shown  on  page  59. 
Such  a  prescription  is  given  as  soon  as  the  man  has  suffi- 
cient strength,  motion  and  muscular  control  to  make  some 
movement  possible,  this  beginning  usually  having  been 
obtained  by  the  preliminary  application  of  physiotherapy. 
For  some  time  the  man  may  be  treated  by  the  suitable 
physiotherapy  methods  together  with  this  simple  occu- 
pational work.  With  the  lessening  of  his  disability  the 
problems  of  his  future  value  to  himself  and  society  are 
taken  up.  The  patient  is  either  given  training  in  work 
which  he  has  done  before  or  takes  up  new  work  which 
will  bring  him  reasonable  financial  return  and  in  which 
his  interest  has  been  already  aroused.  If  his  disability  is 
such  that  he  is  unable  to  return  to  any  occupation  com- 
parable to  the  one  in  which  he  was  engaged  in  civil  life 
after  the  best  surgical  and  vocational  expert  advice  and 
treatment,  he  is  then  trained  in  some  line  in  which  his 
injury  handicaps  him  little.  His  degree  of  disability  in 
its  relation  to  his  future  earning  power  is  calculated  and 
the  difference  made  up  to  him. 

Certain  types  of  vocational  training  have  as  their  main 


VOCATIONAL  THERAPY  81 

object  the  arousing  of  the  patient  from  the  mental  and 
physical  lethargy  into  which  he  is  so  apt  to  fall.  For  this 
purpose  basketry  or  any  simple  creative  work  which  oc- 
cupies his  time  and  interest  has  proven  of  great  value. 
Study  with  a  teacher  of  the  simple  branches  of  learning 
is  also  used  to  good  advantage. 

Interwoven  throughout  a  man's  entire  treatment  is  the 
inspirational  idea.  The  personality  of  the  teacher  is,  of 
course,  of  prime  importance.  These  men  are  so  often  left 
with  the  belief  that  their  disability  has  permanently  un- 
fitted them  for  their  place  in  society  that  the  time  allowed 
them  for  introspection  may  be  more  destructive  to  their 
future  efficiency  than  the  wound  itself.  That  these  men 
do  not  lack  courage  their  glorious  record  has  proven. 
The  problem  lies  in  properly  arousing .  their  grit  and 
stamina,  which,  during  their  stay  in  the  hospital,  has 
become  gradually  inert.  The  man  must  be  made  to  real- 
ize that  the  noblest  of  all  courage  is  the  conquering  of 
physical  handicaps  by  patient  endeavor  and  that  both  the 
instructor  and  the  government  realize  the  quality  of  man- 
hood which  such  a  successful  fight  requires  through  weeks 
and  months  of  persistent  effort.  Too  much  cannot  be 
said  in  praise  of  the  splendid  corps  of  aides  who  are 
carrying  their  own  discouragements  in  addition  to  lifting, 
to  the  best  of  their  ability,  those  of  the  men  whom  they 
serve.  Their  work  will  live  in  the  years  to  come  through 
the  increased  efficiency  with  which  these  men  will  carry 
on. 

For  the  proper  attainment  of  the  man's  rehabilitation 
a  close  and  active  cooperation  must  be  obtained  between 


82  PHYSICAL  RECONSTRUCTION 

the  surgical,  physiotherapy  and  occupational  depart- 
ments. It  is  essential  that  each  understand  and  appre- 
ciate the  scope  of  the  others.  Between  the  man's  voca- 
tional training  and  his  final  status  in  civil  life  stands  a 
most  important  and  efficient  organization,  the  Federal 
Board  for  Vocational  Training.  This  organization  is 
prepared  to  give  expert  advice  on  the  selection  of  future 
work.  It  also  aids  the  man  financially  to  obtain  better 
training  even  to  the  extent  of  paying  his  tuition  in  voca- 
tional training  schools  or  colleges  until  he  has  reached  the 
best  preparation  of  which  he  is  capable.  This  done,  the 
government's  debt  of  honor  to  the  wounded  man  is  met 
and  he  is  returned  to  civil  life  and  self-support.  Let  us 
hope  that  never  again  the  old  pension  system  with  its 
paternalism  and  attendant  evils  will  have  a  place  in  the 
government's  care  of  its  veteran  soldiers. 

In  such  a  book  as  this  no  detailed  description  of  the 
methods  used  in  the  some  two  hundred  and  fifty  occupa- 
tions taught  to  convalescent  soldiers  can  be  undertaken. 
I  will,  however,  briefly  state  a  few  of  the  most  useful 
methods  employed.  At  the  bedsides  are  taught  basketry, 
clay  modeling,  wood  carving,  leather  and  bead  work, 
making  of  simple  toys  and  the  beginning  of  the  studies  of 
English,  mathematics,  stenography,  telegraphy,  etc.  In 
the  shops  are  taught  carpentry,  photography,  automobile 
repairing,  vulcanizing,  modem  machine  shop  practice, 
pattern  making  and  a  wide  variety*  of  other  trades.  In 
the  class  rooms  stenography  and  typewriting,  wireless 
and  the  common  branches  of  language  and  mathematics 
are  a  few  of  the  subjects  taken  up.    This  is  further  de- 


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Fig.  28.     Teaching  the  Beginnings  op  Mechanical  Principles. 
Toys  are  here  being  made  from  tin  cans. 


VOCATIONAL  THERAPY  85 

veloped,  where  possible,  by  field  work  in  electrical  con- 
struction, surveying  and  other  outdoor  occupations. 

Of  special  interest  to  the  general  hospitals  wishing  to 
add  vocational  training  to  their  equipment  is  the  curative 
workshop.  This  is  an  attempt  to  combine  the  simple 
forms  of  vocational  work  requiring  only  inexpensive 
equipment  and  limited  space.  The  therapeutic  indication 
is  the  leading  motive  for  treatment.  In  such  a  workshop 
we  would  find  clay  modeling,  which  has  proven  invalu- 
able in  the  treatment  of  stiff  fingers  and  wrist.  The 
scroll  saw  and  various  lathe  machines  with  adjustable 
pedals  offer  unlimited  possibilities  for  increasing  mobility 
of  hip,  knee  and  ankle.  A  simple  kit  of  tools  suffices  for 
mechanical  drawing,  wood  working,  shoe  making  and 
similar  occupations. 

The  talent  of  an  artist  is  not  destroyed  nor  his  means 
of  expression  lost  when  a  physical  disability  interferes 
with  the  particular  method  of  drawing,  painting,  or  play- 
ing which  he  had  formerly  used.  There  are  several  cases 
on  record  for  artists  following  injury  of  the  right  hand 
have  quickly  learned  to  work  equally  well  with  the  left. 
In  the  same  way  musical  talent  can  be  utilized.  Pro- 
fessional musicians  are  used  in  an  advisory  capacity  to 
aid  men  to  choose  that  instrument  or  mode  of  musical  ex- 
pression which  is  not  interfered  with  by  his  disability. 
There  is  another  value  to  this  type  of  treatment  which 
must  not  be  lost  sight  of  and  that  is  the  inspirational  ef- 
fect of  the  music  itself.  Many  a  man  will  spend  happy 
and  beneficial  hours  in  the  music  studio  instead  of  giving 


86  PHYSICAL  EECONSTRUCTION 

way  to  the  mental  depression  and  discontent  of  the  in- 
valid. 

In  the  early  spring  of  1919  there  were  already  over  fifty 
thousand  patients  in  this  country  under  treatment  by  a 
corps  of  something  over  three  thousand  aides  who  are 
teaching,  as  before  mentioned,  between  two  and  three 
hundred  subjects.  Vocational  therapy  will  see  increasing 
growth  and  development,  and  must  necessarily  be  one  of 
the  last  to  be  discontinued  when  this  big  chapter  of  our 
country's  history  is  closed.  I  wish  again  to  emphasize 
that  the  medical  profession  owes  the  same  intelligent  care 
to  our  great  industrial  army  which  the  government  has 
so  efficiently  given  to  its  veterans  of  the  Great  War. 


Fig.  30.     Musical  Knowledge  Reapplied  to  an  Instrument  the  Man's 
Disability  Will  Allow  Him  to  Play. 
Pleasure  and  higher  emotional  tone  are  derived  from  the  production  of  good 
music. 

Fig.  31.     Automobile  Repair  Shop. 

This  is  one  of  the  most  practical,  valuable  and  popular  forms  of  vocatio 
therapy. 

Fig.  32.    Wood  Working. 

Gives    many  possibilities  for  self  expression,  arouses  the  creative  interest 
and  exercises  almost  innumerable  muscle  groups. 


VOCATIONAL  THERAPY  89 

(Orthopedists  have  found  the  following  simplified  form  useful 
in  briefly  outlining  the  reconstruction  treatment  which  they  con- 
sidered best  suited  to  the  needs  of  the  patient.) 

EDUCATIONAL  SERVICE 

U.  S.  Army  Base  Hospital 

Camp  Meade,  Md. 


MEDICAL  OFFICER'S  PRESCRIPTION 

Name  

Ward   191 . 

Diagnosis    


Probable  length   of  stay   in   hospital weeks. 

Probable    condition    after    completion    of    hospital    treatment 


Functional  result  to  be   attained. 


In  orthopedic  cases  check  below: 

.Abduction  ..Thumb  ..R....L 

.Adduction  ..Finger 

.  Flexion  '  . .  Wrist 

.Extension  ..Elbow 

.  Pronation  . .  Shoulder 

.  Supination  . .  Back 

.  Circumduction  . .  Toes 

. .  Mid-Tarsus 

.  .Ankle 

..Knee 

..Hip 

Remarks    


90 


PHYSICAL  EECONSTRUCTION 


PRESCRIPTION  BLANK.  FOR  VOCATIONAL  THERAPY 

Please  check  below  the  general  class  to  which  this  man's  dis- 
ability belongs,  using  double  check  for  major  disability  and  single 
check  for  minor.  • 


MEDICAL   CONDITIONS 

Cardio-vascular 

Pulmonary  Tuberculosis 

Fimctional  Neurosis 

Insanity 

Nephritis 

(rastro-intestinal 

Skin  Disease 

Gassed 

Convalescent 

Other  general  medical 


SUBOICAL  CONDITIONS 

Orthopedic 

Amputation 

Eye,  Ear,  Nose 

Throat  Disease  or  Wound 

Nervous  System 

Blindness 

Deafness 

Speech  Defect 

Severe  Injury  to  Face  or  Jaw 

Venereal  Disease  or  Sequelae 

Surgical  Condition  of 

G.-U.  System 

Venereal 

Non-Venereal 

Other  surgical  conditions 

Convalescent 


This  man  is  ready  for  assignments  checked  below    (please  i» 
elude  all  of  which  he  is  capable)  : 

Work  in  wards:     Mental Physical 

Classroom   work  not   to  exceed hours  and minutes 

daily. 

Shop  or  farm  work .... 
Hours  per  day .... 

Light Heavy 

Outdoor Indoor 

To  be  avoided 


Medical  Officer's  Signature 


(This  prescription  will  be  filed  in  the  Surgeon  General's  Office 
as  a  part  of  the  Physical  Reconstruction  Register.) 


PART  II 
ORTHOPEDICS 

Chapter  V 
CONGENITAL  DEFECTS 

Club  Foot.  As  this  common  condition  is  much  more 
often  congenital  than  acquired,  the  congenital  type  only- 
will  be  considered.  There  are  four  types.  The  deformed 
foot  (talipes)  may  be,  1.  Extended  and  everted,  equino 
valgus.  2.  Extended  and  inverted,  equino  varus.  3. 
Flexed  and  everted,  calcaneo  valgus.  4.  Flexed  and  in- 
verted, calcaxeo  varus.  Simple  talipes  equinus  is  dis- 
cussed under  muscle-bound  foot. 

These  deformities  vary  greatly  in  their  resistance  to 
corrective  measures.  Eesistance  in  any  given  case  in- 
creases with  age,  therefore  treatment  should  be  begun 
as  early  as  possible.  In  very  slight  cases  manual  correc- 
tion alone  may  suffice.  In  the  more  marked  types  a  se- 
ries of  casts  must  be  used.  In  the  commonest  type, 
equino  varus,  emphasis  must  first  be  placed  upon  straight- 
ening the  foot,  flexion  being  easily  obtained  later  on  if 
necessary  by  tenotomy.  The  series  of  casts  should  be 
as  nearly  continuous  as  possible  and  each  should  remain 
on  about  two  weeks. 

Hip  Dislocation.  This  condition  is  more  common  than 
is  generally  realized  and  the  difficulty  of  reading  X-ray 

91 


92  ORTHOPEDICS 

plates  makes  it  necessary  to  use  the  utmost  care  in  diag- 
nosis. A  neglected  hip  means  an  undeveloped  or  shallow 
acetabulum  into  which  it  may  be  impossible  to  place  the 
head  of  the  femur  later  on.  It  interferes  with  the  devel- 
opment of  the  bones  and  tends  to  an  asymmetrical  pelvis. 
The  table  devised  by  Hibbs  of  New  York  has  been  used 
very  successfully  in  diflScult  cases.  Care  must  be  taken 
not  to  overreduce  and  create  a  dislocation  in  the  oppo- 
site direction,  as  has  often  been  done. 

BICKETS 

Cause.  We  find  rickets  most  prevalent  among  negro 
and  Italian  children  of  the  first  generation.  It  is  caused 
by  a  lack  of  suflBcient  lime  salts  in  the  bone,  primarily 
because  they  are  not  supplied  in  proper  amount  in  the 
diet.  The  prolonged  nursing  of  children  to  the  fifteenth 
or  even  eighteenth  month  is  perhaps  the  commonest  cause. 
The  dependence  upon  macaroni  as  the  staple  Italian  diet 
accounts  for  a  good  deal  of  it. 

Diagnosis.  The  large,  square  head  with  overhanging 
forehead  and  delayed  closing  of  the  f ontanelles ;  enlarged 
epiphyses  of  the  long  bones;  the  beading  of  the  sternal 
end  of  the  ribs,  so  called  rachitic  rosary ;  the  prominent, 
hard  abdomen,  and  a  tendency  to  draw  up  the  legs,  are 
the  main  early  symptoms  of  the  disease.  Later  on,  bow- 
ing of  the  legs  or  knock  knees  develop. 

Treatment.  Improved  hygiene,  especially  in  regard 
to  diet,  fruit  juices,  particularly  orange,  green  vege- 
tables, fresh  milk,  eggs,  etc.,  is  essential.  Massage  is  a 
yaluable  adjunct  of  the  treatment.    Braces  are  usually 


CONGENITAL  DEFECTS  93 

needed  and  must  be  faithfully  worn.  Even  in  rather  se- 
vere types  of  bow  leg  one  brace  will  often  suffice.  If  not 
it  can  be  changed  over  or  an  additional  brace  made  for 
the  other  leg.  Anterior  and  very  severe  lateral  bowing 
often  call  for  surgical  interference.  A  careful  study  of 
the  epiphyses  by  the  X-ray  is  very  essential  in  order  to 
determine  the  optimum  time  to  operate  when  true  bone 
has  just  begun  to  be  rapidly  deposited.  Knock  knee  as 
well  may  call  for  surgical  intervention  guided  by  the 
same  principles.  It  must  be  emphasized  that  permanent 
injury  may  be  done  to  the  knee  joint  rather  early  in 
neglected  cases  and  that,  with  each  additional  degree  of 
deviation  from  the  normal  line  of  weight  transmission, 
a  very  great  amount  of  additional  strain  is  thrown  upon 
the  structures  of  the  knee. 

Coxa  Vara.  This  is  a  decrease  in  the  angle  between 
the  surgical  neck  and  the  shaft  of  the  femur  with  con- 
sequent shortening  of  the  affected  leg  and  change  in  the 
normal  line  of  weight  transmission.  Its  effect  is  similar 
to  but  not  usually  as  pronounced  as  that  described  as 
resulting  from  congenital  hip  dislocations.  It  calls  for 
a  long  stilt  brace  on  the  affected  leg  to  transmit  the 
weight  of  the  body  from  the  pelvis  to  the  ground,  the 
weight  of  the  leg  giving  some  extension.  The  shoe  on  the 
unaffected  side  should  be  built  up. 

Spastic  Paralysis.  Central  motor  neurone  lesions  most 
often  found  in  prolonged  labor  or  instrumental  delivery 
result  in  spastic  paralysis.  The  only  immediate  relief  of 
this  condition  is  decompression,  as  performed  with  con- 
giderable  success  by  Dr.  Sharpe  of  New  York,  but  even 


94  ORTHOPEDICS 

under  most  favorable  conditions  a  happy  result  is  not 
certain.  The  associated  retardation  of  mental  develop- 
ment greatly  complicates  the  problem  of  neuro-muscular 
education.  Treatment  by  effleurage  and  passive  stretch- 
ing should  precede  exercises  for  coordination  and  bal- 
ance. To  bring  lasting  results  these  must  be  extended 
over  a  span  of  years.  Every  case  can  be  improved  and 
should  be  a  challenge  to  us  to  obtain  the  greatest  improve- 
ment possible,  even  when  complete  recovery  is  hopeless. 


Fig.  33.    Carriage  which  Reduces  Friction  axd  on  a  Smooth  Surface 
Allows  Wide  Range  of  Movement  with  Slight  Effort. 


Fig.  34. 


Wire  Cockup  Splint  for  Wrist  Drop,  Light  in  Weight,  and  Re- 
quires No  Bandaging. 


Chapter  VI 
INFANTILE  PARALYSIS 

In  infantile  paralysis  the  lesion  is  a  destructive  one  of 
the  anterior  horn  cells  of  the  cord  and  the  lower  motor 
neurones  and  almost  always  the  resulting  paralysis  is 
a  flaccid  one.  The  trophic  nerves  are  likewise  affected 
and  the  part  tends  to  decrease  in  bulk  as  well  as  in  power. 
During  the  active  stage,  and  while  ^ny  tenderness  per- 
sists, the  patient  should  be  kept  immobile.  This  is  best 
done  by  means  of  a  cast  or  splint,  but  immediately  there- 
after for  an  extended  period  of  time,  daily  treatment 
consisting  of  massage,  exercise,  support  and  sometimes 
heat,  should  be  instituted.  Massage  should  be  mainly 
fine,  deep  petrissage  for  stimulative  effect.  The  operator 
must  be  sure  that  he  is  getting  direct  action  on  the  few 
fibers  that  may  remain  alive  under  the  usual  thick  coat- 
ing of  connective  tissue  and  fat. 

Exercises.  In  general,  small  and  often  repeated  doses 
bring  the  best  results.  Like  the  burning  out  of  a  weak 
motor,  lasting  harm  may  be  caused  by  overdoing.  Many 
devices  for  counter-weighting  the  limb  have  been  used, 
thereby  giving  the  patient  the  early  and  stimulating  ef- 
fect of  being  able  to  move  the  limb  actively.  We  have 
used  a  small  carriage,  consisting  of  a  grooved  plat- 
form mounted  on  casters  and  with  a  retaining  strap. 

97 


98  ORTHOPEDICS 

This  is  easily  made,  and  by  overcoming  to  a  large  degree 
the  friction  of  even  a  smooth  table  surface,  will  allow 
great  amplitude  of  active  movement  very  early  in  the 
treatment. 

Let  us  consider  as  a  typical  case  a  paralyzed  arm  in 
which  the  adductor  muscle  group  is  partially  affected,  the 
abductors  of  the  arm,  especially  the  deltoid,  the  trapezius 
and  the  supraspinatus  have  regained  their  strength  but 
slightly,  the  flexors  and  extensors  of  the  elbow  have  very 
little  power  remaining,  and  the  muscles  of  the  forearm 
and  hand  are  practically  powerless. 

The  following  three  programs  of  exercise,  preceded  by 
the  application  of  massage  and  heat,  are  suggested  as 
giving,  when  used  in  rotation,  a  variety,  which  is  of 
value  in  retaining  the  patient's  interest. 

PROGRAM  I 

The  patient  sitting,  affected  side  toward  table,  hand  strapped 
on  carriage.     • 

1.  "Wide  sweep  of  arm  forward  and  backward. 

2.  Flexion  and  extension  of  the  elbow  to  the  side. 

3.  Wide  sweep  of  arm  with  one  or  more  attempts  to  stop  and 
start  again  at  definite  points. 

4.  Small  hand  circles,  elbow  free,  done  a  few  times  in  each 
direction. 

5.  Flexion  and  extension  of  the  elbow,  fixed. 

6.  Patient  leaning  far  forward,  wide  sweeps  of  the  arm., 
(The  plane  of  the  movement  of  the  arm  in  relation  to  the  body 
is  thus  changed  from  horizontal  to  vertical  and  valuable  help  is 
given  in  stretching  the  adductors.) 

7.  Forearm  fixed,  abduction  and  adduction  of  the  wrist. 


INFANTILE  PARALYSIS  99 

8.  Hand  turned,  ulnar  side  down,  flexion  and  extension  of 
the  wrist. 

9,  Patient  prone  on  the  table,  wide  sweep  of  the  arm  from 
iide  to  side  overhead.  (On  a  narrow  table  use  as  wide  a  move- 
ment as  possible  directly  above  the  head.) 

PBOGBAM  n.      FREE  EXERCISES 

Patient  supine  on  the  table.  These  exercises  may  be  done 
by  the  affected  arm  only,  by  both  together  or  alternately. 
Greater  variety  of  neuro-muscular  training  may  be  secured  by 
these  different  combinations. 

1.  Raise  arm  fore  upward,  carry  above  head  and  return. 

2.  Place  hand  on  hip  and  return. 

3.  Carry  arm  sideward  up  to  head  and  return. 

4.  Carry  arm  across  body  to  opposite  side  of  waist  and  return. 

5.  Snap  hand  to  shoulder  and  return,  aided  by  lifting  elbow 
sideward  if  necessary. 

6.  Carry  arm  sideward,  flex  elbow,  bringing  hand  to  axilla, 
straighten  sideward  and  return, 

7.  Flex  elbow,  bringing  hand  to  opposite  shoulder  and  return. 

8.  Supinate  and  pronate  the  forearm.  (In  this  position  this 
may  be  a  shoulder  exercise.) 

9.  Flex  elbow  to  right  angle,  supported  if  necessary  and 
pronate.     (This  position  eliminates  shoulder  assistance.) 

10.  Flex  elbow,  hand  on  neck  to  shorten  leverage,  extend 
shoulder  upward  and  return  several  times,  return  hand  to  side. 

PROGRAM  m.      RESISTIVE  EXERCISES 

Fingers.  1.  A  well-fitting  kid  glove  with  small  rings  at  the 
finger  tips,  to  which  are  attached  very  light  weights  by  means 
of  strings,  and  used  for  flexion  of  fingers  singly  or  together 
with  the  hand  supine,  the  strings  running  over  a  wrist  roller 


100  ORTHOPEDICS 

or  a  row  of  spools.    Pronate  the  hand  for  finger  extension  in 
similar  manner. 

2.  Finger  flexion  machine — finger  tread-mill. 

Wrist.    1.  Wrist  roller. 

2.  Supination  and  pronation  machine. 

3.  Abduction  and  adduction  machine  (McKenzie). 
With  overhead  chest  weights. 

Elbow.  1.  With  hand  encased  in  glove,  if  necessary,  and  at- 
tached to  overhead  pulley  handle,  flex  elbow. 

2.  With  arm  at  side  allow  weights  to  flex  elbow  as  far  as 
the  control  of  the  patient  will  allow,  and  extend  downward. 

Shoulder.  1.  From  extended  arm,  carry  arm  obliquely  fore 
downward. 

2.  From  extended  arm,  carry  arm  side  downward. 

3.  From  extended  arm,  carry  arm  obliquely  back  downward. 

4.  Arm  raised  sideward  at  shoulder  level,  carry  forward  and 
return,  carry  backward  and  return. 

Without  Chest  Weights.  Patient  seated  in  chair,  back  to 
operator.  Operator  places  hands  on  tips  of  shoulders  while 
patient  (1)  pulls  the  shoulder  forward,  (2)  lifts  it  up,  (3) 
pushes  it  backward. 

Most  of  the  above  exercises  can  be  worked  out  with 
the  shoulder  or  low  chest  weight,  especially  with  the 
patient  lying  supine,  head  toward  the  weights.  The 
overhead  pulley,  however,  gives  the  additional  advantage 
of  passive  stretching  of  the  stronger,  and  frequently 
shortened,  adductor  groups.  The  other,  and  still  more 
common,  result  of  infantile  paralysis  is  a  partially 
paralyzed  leg.  We  will  take  as  our  basis  a  leg  in  which 
all  the  muscles  of  the  thigh  have  a  fair  amount  of  power 
present,  the  extensors  of  the  foot  are  considerably  weak- 
ened, and  the  flexors  are  almost  powerless. 


INFANTILE  PARALYSIS  101 

PROGRAM  I 

Patient  lying  supine. 

1.  a.  Operator  grasps  the  fore  part  of  the  foot  with  one  hand, 
the  heel  with  the  other  and  passively  flexes  the  toes  and  the  fore 
part  of  the  foot. 

b.  With  the  right  hand  grasping  the  fore  part  of  the  foot, 
the  thumb  on  the  ball,  the  left  hand  grasping  behind  the  heel, 
the  operator  vigorously  flexes  the  foot  with  an  attempt  at  stretch- 
ing the  gastrocnemius  and  the  calf  muscles  and,  if  necessary, 
slightly  assists  the  extension.  "With  the  left  hand  working  in 
the  opposite  direction,  he  overcomes  the  patient's  movement  at 
the  hip,  because,  in  attempting  to  extend  the  foot,  the  patient 
will  press  down  with  the  whole  leg,  and  vice  versa. 

2.  The  operator,  supporting  under  the  knee  with  the  right 
hand,  and  the  left  under  the  ankle,  is  able  to  give  any  needed 
amount  of  assistance  to  the  extension  of  the  leg. 

3.  Grasping  behind  the  ankle  and  giving  support  over  the 
knee,  if  necessary,  he  assists  the  flexion  of  the  hip  with  straight 
leg. 

4.  From  the  same  starting  position  abduction  and  adduction 
are  given,  the  operator  carrying  the  weight  of  the  leg. 

5.  Deep  flexion  of  the  thigh  is  done  with  the  same  assistance. 

6.  The  carriage  is  placed  under  the  ankle  for  active  abduc- 
tion and  adduction. 

Patient  lying  on  affected  side. 

1.  a.  Place  the  affected  ankle  on  carriage,  knee  fixed,  for  active 
flexion  and  extension. 
b.  With  knee  bending,  flex  the  thigh  acutely. 
Patient  lying  prone. 

1.  The  knee  is  flexed  at  right  angles  and  held  by  operator  or 
patient  for  rotation  of  the  thigh. 

2.  Flexion  and  extension  of  the  knee. 


102  ORTHOPEDICS 

3.  Overextension  of  the  thigh  by  backward  and  upward  pull 
of  the  operator. 

4.  Knee  flexed,  circling  of  the  foot  both  ways,  which  is  a 
combination  of  1  and  2. 

There  are  various  tread  mills  and  extension  weight 
machines,  which  are  of  value.  Machines  for  flexion,  ex- 
tension and  circumduction  of  the  ankle  all  have  their 
place,  if  available. 

It  is  taken  for  granted  that  the  operator  will  vary 
and  adjust  his  exercises  exactly  in  relation  to  the 
strength  of  each  group  of  the  patient's  muscles,  follow- 
ing the  general  rule  that  the  movements  often  have  to 
be  entirely  passive  at  first,  with  a  slowly  increasing 
amount  of  assistance  by  the  patient,  and  final  develop- 
ment into  active  or  even  resistive  movement.  Again  I 
would  caution  against  too  much  work.  An  average  of 
four  to  eight  repetitions  of  each  exercise  in  the  program 
selected  are  sufficient  for  each  treatment. 

Support,  especially  a  brace  in  the  case  of  the  leg,  is 
almost  always  essential  and  when  needed  should  be  worn 
constantly.  The  deformities  we  fear,  overextension  of 
the  knee  and  drop  foot,  are  generally  the  result  of  the 
neglect  of  this  needed  support.  Parents  often  need  the 
truth  driven  home  to  them  that  it  is  the  brace  which  car- 
ries the  child,  when  to  them  it  appears  that  the  child  is 
lugging  around  a  heavy  extra  weight.  A  late  compli- 
cation, coming  from  two  to  four  or  even  six  years  after 
the  disease,  is  scoliosis,  and  this  must  be  watched  for 
from  time  to  time.    Indeed,  Doctors  Hibbs,  Farrell  and 


INFANTILE  PARALYSIS         .         103 

Humphries,  from  their  work  in  the  New  York  Orthopedic 
Hospital,  have  come  to  the  conclusion  that  infantile  paral- 
ysis is  the  most  common  single  factor  in  the  causation  of 
scoliosis.  Late  sequelae  in  unfavorable  or  neglected 
cases  may  demand  tenotomy  or  muscle  transplantation, 
but  these  operative  procedures  are  not  as  early  resorted 
to  as  heretofore.  They  should  only  follow  several  years 
of  patient  endeavor  to  secure  the  fullest  results  that 
may  be  hoped  for  from  exercise,  and,  if  done,  must  in  turn 
be  followed  by  reeducation.  Recent  rather  brilliant  re- 
sults in  apparently  hopeless  cases  have  been  achieved 
by  baking  for  a  considerable  time  in  moderate  tempera- 
ture. One  must  avoid  allowing  the  monotony  of  the  work 
to  get  one  into  a  rut  and  to  make  one  overlook  the  in- 
dividual problem  incident  to  each  case.  Nothing  in  our 
field  of  work  brings  richer  reward  than  patient,  intelli- 
gent work  with  this  distressing  condition. 

Drop  Wrist.  This  is  another  common  type  of  paraly- 
sis, which  may  follow  fractures  of  the  humerus,  or  lead 
poisoning.  It  is  the  paralysis  of  the  extensors  of  the 
wrist  and  exercises  as  outlined  above  are  applicable. 
Splinting  in  extension  must  be  maintained  constantly. 

NEBVE  INJUBIES  IN  WAB 

Injuries  to  the  peripheral  nerves  are  very  common  in 
modem  warfare  because  of  the  extensive  lacerations  of 
the  soft  tissue  caused  by  many  types  of  projectiles.  In 
fact  the  high  velocity  bullet  at  mid-range  and  gas  shells 
are  about  the  only  missiles  that  do  not  make  this  kind  of 
wound.     *  *  The  Orthopedic  Treatment  of  Gunshot  In« 


104  ORTHOPEDICS 

juries,'*  by  Leo  Mayer,  covers  this  field  in  a  very  satis- 
factory manner. 

Neurological  examinations  were  made  at  the  Field  or 
Evacuation  Hospital  when  possible  and  splints  supplied 
if  the  injuries  were  extensive.  It  is  important  to  re- 
member that  all  wounds  of  the  soft  parts  are  now  splinted 
where  practicable.  I  will  attempt  only  briefly  to  out- 
line the  diagnosis  and  treatment  of  injuries  of  the  most 
common  type. 

Upper  Extremity.  1.  Brachial  plexus  injuries  are  oc- 
casioned by  axillary  or  supraclavicular  wounds.  2.  Cir- 
cumflex. The  teres  minor  and  deltoid  are  affected,  so 
that  full  abduction  of  the  arm  is  impossible.  3.  Mus- 
culocutaneous. Weakness  of  elbow  flexion  without  areas 
of  anesthesia  occur.  4.  Musculospiral.  This  very  com- 
mon injury  makes  it  impossible  to  extend  the  wrist  or 
thumb  and  the  proximal  phalanges  of  the  fingers  are  also 
affected.  The  distal  phalanges  can  be  extended,  supina- 
tion and  the  action  of  the  triceps  are  weak,  and  small 
areas  of  anesthesia  may  be  present  on  the  base  of  the 
thumb.  5.  Median.  Flexion  of  the  fingers  and  thumb  is 
absent  and  there  is  anesthesia  over  the  first  two  fingers 
and  the  outer  half  of  the  third.  To  test  paralysis  of 
pronation  have  the  elbow  fixed.  6.  Ulnar.  Fourth  and 
fifth  finger  flexion  is  weak  and  there  is  inability  to  spread 
the  fingers  to  the  normal  extent.  The  fifth  finger  and  the 
inner  side  of  the  fourth  is  anesthetic. 

Lower  Extremity.  1.  Sciatic.  There  is  weakness  of 
knee  flexors  and  complete  paralysis  of  the  foot  with 
nearly  total  anesthesia.    2.  External  popliteal.    Dorsal 


INFANTILE  PARALYSIS  105 

flexion  and  eversion  are  absent  and  the  dorsum  of  the 
foot  and  toes  is  anesthetic.  3.  Internal  popliteal.  Plan- 
tar flexion  is  weak  or  absent  with  anesthesia  of  the  sole 
of  the  foot.  4.  Musculocutaneous.  Foot  eversion  is  weak 
and  there  is  anesthesia  over  dorsum  of  foot.  5.  Anterior 
tibial.  Dorsal  flexion  is  absent  with  anesthesia  of  the 
big  toe  and  part  of  the  second  toe.  6.  Posterior  tibial. 
Adduction  is  weakened  and  toe  flexion  is  absent. 

Treatment.  Early  treatment  by  splinting  in  such  a 
way  as  to  relax  the  fibers  of  the  affected  muscles  is  essen- 
tial. This  general  rule  may  be  accepted  in  the  case  of 
ulnar  nerve  injury  because  of  the  danger  of  contracture, 
hence  the  fingers  should  be  kept  straight.  Attempt  to 
bring  the  severed  ends  of  the  nerve  into  as  close  approxi- 
mation as  possible.  Plaster,  leather  or  metal  may  be 
used  for  splinting.  In  injury  to  the  musculospiral  nerve 
keep  the  hand  extended.  It  is  well  to  abduct  the  thumb 
also.  The  proximal  phalanges  of  the  fingers  must  be 
kept  extended  by  the  cockup  splint. 


Chapter  VII 
THE  SPINE— DISEASES  AND  INJURIES 

Anatomy.  The  spine  is  a  flexible  column  made  up 
of  a  series  of  block-like  bones,  the  vertebrae.  There  are 
thirty-three  in  the  entire  column,  seven  neck  or  cervical, 
twelve  dorsal  or  thoracic,  five  lower  back  or  lumbar — 
five  fused  together  for  the  sacrum  and  four  fused  to 
form  the  coccyx.  In  general,  the  vertebrsB  consist  of 
two  essential  portions,  the  heavy  solid  body  in  the  front 
and  the  neural  arch  formed  by  the  two  pedicles  and  two 
laminae,  with  their  processes,  two  transverse,  four  articu- 
lar and  one  spinous.  The  bone  structure  is  more  dense  in 
the  neural  arch  than  in  the  body. 

The  bodies,  with  their  intervertebral,  cartilaginous 
pads  are  able  to  rotate  slightly,  one  upon  the  other  in 
what  more  or  less  closely  approximates  the  horizontal 
plane.  The  articular  processes,  however,  are  placed  in 
an  oblique  plane,  the  superior  backward  and  upward,  the 
inferior  forward  and  downward  in  direction.  With  the 
spine  erect  these  articulations  act  as  a  check  to  rotation 
between  the  bodies.  The  anterior  common  ligament, 
binding  the  front  of  the  bodies  together,  is  not  nearly  as 
strong  as  the  combined  interspinous  and  supraspinous 
ligaments.  There  is  a  great  difference  in  the  mobility 
of  the  various  parts  of  the  spine.    We  find  the  most  mo- 

106 


THE  SPINE— DISEASES  AND  INJURIES    107 

bility  between  atlas  and  axis;  flexion  forward  is  least 
in  the  dorsal,  then  cervical,  most  in  lumbar;  extension 
backward,  the  same ;  rotation  is  most  in  the  cervical. 

Tvhercvlosis  of  the  Spine.  ("Pott's  disease.")  The 
spine  is  one  of  the  most  common  regions  at  which  the 
tubercle  bacillus  attacks  the  bony  skeleton.  One  or  more 
vertebrae  may  be  involved  either  as  a  primary  or  a  sec- 
ondary focus  of  infection.  The  bodies  of  the  vertebrae 
are  usually  the  parts  first  invaded.  Points  of  lowered 
resistance  caused  by  trauma  are  often  affected  or  such  a 
trauma  may  bring  to  light  a  slowly  developing  and  here- 
tofore unsuspected  infection  and  cause  its  rapid  spread. 
The  "cancellous  nature  of  the  bones  permit  early  destruc- 
tion with  crushing  in  wherever  the  infection  is  exten- 
sive. The  collapse  of  the  body  of  one  or  more  vertebrae 
makes  more  prominent  the  spinous  process  and  forms 
on  the  back  the  distinctive  angular  deformity  known  as 
a  gibbus.  Complete  paraplegia  from  pressure  on  the 
cord  may  occur.  Spinal  caries  is  more  frequently  found 
from  the  fourth  to  the  fifteenth  year. 

Symptoms.  Knowledge  of  tuberculosis  in  the  patient 
or  his  family  should  make  us  use  extreme  care  to  rule 
out  this  condition  in  the  presence  of  any  obscure  symp- 
toms pointing  to  the  back.  Usually  they  are  pain,  pro- 
tective spasm  with  resulting  rigidity,  angular  deformity 
and  the  general  signs  of  a  chronic  infection,  although  in 
early  stages  this  may.not  be  present.  Rigidity  alone  is 
a  symptom  of  great  significance  and  sometimes  a  suflB- 
cient  basis  for  a  positive  diagnosis.  The  X-ray  should  al- 
ways be  used  and  will  often  confirm  the  diagnosis.    It 


108  ORTHOPEDICS 

is  of  the  utmost  importance  to  differentiate  this  condi- 
tion from  scoliosis  and  kyphosis  since  the  treatment  for 
tuberculons  spine  by  exercise  would  do  certain  injury. 
I  have  seen  them  exist  together,  with  the  postural  defects 
the  more  obvious. 

Treatment.  Pott's  disease  demands  the  same  consti- 
tutional treatment  as  tuberculous  manifestations  else- 
where in  the  body.  The  local  treatment  consists  in  fixa- 
tion and  extension  by  means  of  cast,  brace,  stretcher 
frame,  or  by  the  operative  establishment  of  immobility, 
secured  by  a  bone  graft  from  the  tibia  implanted  into 
the  split  spinous  processes  and  extending  one  or  two 
vertebrae  above  and  below  the  lesion  as  devised  by 
Albee  of  New  York.  Another  successful  method  is  that 
of  Hibbs,  consisting  in  a  partial  resection  and  fusion  of 
the  laminae.  This  operation  has  the  advantage  of  mak- 
ing but  one  incision  and  eliminates  the  slight  promi- 
nence of  the  bone  graft.  Where  the  lesion  is  in  the 
cervical  section  an  extension  of  the  brace  or  cast  which 
will  lift  up  the  head  is  necessary.  For  example,  the 
Taylor  brace  with  head  support  (jury  mast)  is  often 
used.  Grafts  which  prevent  collapse  have  been  suo- 
cessfuly  planted  into  the  sacrum.  A  complication  which 
necessitates  special  attention  is  abscess  formation.  They 
commonly  follow  the  course  of  the  psoas  muscle,  and 
point  in  the  inner  side  of  the  thigh,  but  are  subject  to  a 
wide  variation  and  may  point  in  almost  any  direction 
from  the  seat  of  the  lesion.  Aspiration  under  aseptio 
precautions  is  sometimes  advisable.  Sinuses  already 
formed  should  be  injected  with  Beck's  bismuth  paste. 


THE  SPINE— DISEASES  AND  INJURIES    109 

They  should  be  carefully  dressed  to  prevent  mixed  in- 
fection and  will  usually  clear  up  when  proper  measures 
are  instituted  at  the  seat  of  the  original  lesion. 

TRAUMATIC   INJURIES 

Strain  and  Sprain.  Prolonged  carrying  of  heavy 
weights  when  the  patient  is  not  in  proper  condition  may 
lead  to  back  strain.  An  example  of  this  is  the  heavy 
marching  order  on  the  part  of  the  recruit  not  yet  thor- 
oughly hardened.  Weight  lifting  in  the  stooping  posture 
is  the  common  cause  of  lower  back  strains.  Sudden 
twisting  or  falls  upon  the  back  or  the  awkward  landing 
after  jumping,  may  lead  to  quite  severe  sprains  of  any 
of  the  various  ligaments. 

Treatment  by  means  of  heat,  massage,  rest,  and  sup- 
port is  indicated. 

In  sacro-iliac  sprain  the  following  strapping  will  be 
found  most  serviceable:  The  patient  lying  prone,  the 
surgeon  fixes  the  strap,  which  should  be  the  full  width  of 
the  roller,  3  to  5  inches  in  front  of  the  anterior  superior 
spine  on  the  further  side  of  the  patient.  The  patient 
then  rolls  slowly  away  from  the  surgeon,  who  applies 
the  strap  tightly  obliquely  upward,  ending  just  below  the 
twelfth  rib  of  the  opposite  side.  The  procedure  is  then 
repeated  in  the  reverse  direction,  the  two,  broad,  snugly 
fitting  straps  crossing  over  the  sacrum.  They  may  be 
reinforced  by  a  short  vertical  strap  of  the  same  width 
over  the  sacrum  and  one  or  two  lumbar  vertebrae.  Most 
corsets  or  belts  which  fasten  in  front  aggravate  the  con- 


no  ORTHOPEDICS 

dition  because  their  pull  tends  to  open  the  saoro-iliao 
joints. 

Bruises.  Bruises  of  the  muscles  and  ligaments  along 
the  spine  show,  beside  the  swelling  and  discoloration 
which  may  be  present,  a  localized  tenderness  on  one  side 
of  the  spine.  The  spinous  processes  should  not  be  tender 
in  this  injury. 

Fractures  and  Dislocations.    Spinal  fractures  are  rare. 

Cervical  Region.  This  region,  because  of  its  mobility, 
is  prone  to  dislocations,  but  fractures  do  occur.  Slight 
lesions  only  need  treatment,  as  a  fatal  outcome  is  almost 
certain  in  severe  injury.  Dislocation  of  the  atlas  an- 
teriorly on  the  axis  is  sometimes  seen.  Slight  displace- 
ment, if  associated  with  fracture  of  the  odontoid  process, 
may  not  be  fatal.  In  this  lesion  the  short  spine  of  the 
,axis  may  be  palpated.  The  head  is  bent  forward.  Slight 
lateral  dislocation  at  this  joint,  or  between  the  other 
<jervical  vertebrae,  is  not  uncommon  and  gives  no  other 
symptoms  than  slight  pain  and  rigidity  of  the  neck. 

Treatment.  After  anesthesia,  gentle  hyperextension 
maintained  by  a  jury  mast  is  necessary.  In  lateral  dis- 
placements tilt  the  head  toward  the  opposite  side,  in- 
creasing the  deformity,  but  unlocking  the  facets;  turn 
the  head  toward  the  deformity  to  raise  the  caught  facet 
and  then  re-turn  the  head  to  a  correct  position. 

The  third,  fourth,  or  fifth  cervical  vertebrae  may  be 
fractured  or  partially  dislocated  by  blows  or  falls  on  the 
head.  Such  injuries  are  reduced  as  described,  under 
anesthesia,  if  required.  When  removal  of  the  patient  is 
necessary  in  any  of  the  above  injuries  some  means  of  ex- 


THE  SPINE— DISEASES  AND  INJURIES    111 

tension  is  essential.  A  temporary  collar  of  folded  stiff 
paper,  plaster  or  other  stiff  material  will  attain  this  re- 
sult. 

Dorsal  Region.  In  the  dorsal  vertebrae  the  bodies  or 
laminae  are  seldom  fractured  except  in  fatal  accidents. 
The  spinous  processes,  however,  are  subject  to  fracture. 
The  symptoms  are  sharp  pain,  crepitus,  and  abnormal 
mobility  on  palpation  of  the  spinous  process.  Extravasa- 
tion of  blood  in  the  tissues  may  be  noticed.  Deviation 
of  a  single  spinous  process,  which  may  be  gently  pressed 
back  to  its  normal  position,  and  the  localization  of  pain 
close  to  the  skin  are  other  prominent  symptoms.  The 
examination  should  be  supplemented  and  the  diagnosis 
confirmed  by  the  X-ray.  In  the  lower  cervical  and  upper 
dorsal  regions  a  support  transferring  the  weight  to  the 
pelvis  is  efficient  and  permits  of  the  patient  getting  about 
fairly  early.  In  lower  dorsal  injuries  this  complete  re- 
lief from  weight  bearing  is  difficult  to  attain.  At  least 
two  months  in  the  recumbent  position  is  required  for 
absolute  safety. 

Lumbar  Region.  The  mobility  of  this  region  and  the 
fact  that  it  is  unprotected  by  bony  structures,  as  the  dor- 
sal region  is,  subject  it  to  injury.  Dislocation  is  ex- 
tremely rare  and  even  in  fracture  of  the  bodies  we  do  not 
as  a  rule  get  marked  displacement.  Fatal  outcome  of 
such  injuries  is  rare  since  they  are  below  the  level  of  the 
cord.  Careful  examination  is  required  as  it  is  easy  td 
overlook  fracture  in  this  region.  Any  change  in  the  nor- 
mal lumbar  curve  is  suspicious.  X-ray  should  be  used 
in  diagnosis  whenever  possible.    The  appearance  of  lum- 


112  ORTHOPEDICS 

bar  deformity,  particularly  backward  displacement,  re- 
quires extension  on  the  stretcher  frame.  As  is  the  case 
with  lower  dorsal  fracture,  it  is  impossible  to  completely 
relieve  weight  bearing.  Treatment  in  the  horizontal  po- 
sition must  be  continued  six  to  ten  weeks. 

Partial  dislocation  forward  of  the  fifth  lumbar  verte- 
bra on  the  sacrum  is  becoming  increasingly  common  and 
often  follows  relaxation  of  the  sacro-lumbar  ligament. 
This  is  due  to  the  abnormal  obliquity  of  the  pelvis,  which 
occurs  in  lordosis,  and  which  is  often  associated  with  the 
wearing  of  high  heels.  This  is  a  common  cause  of  back- 
ache and  it  is  most  difficult  to  obtain  fixation  by  means 
of  a  brace.  Treatment  by  orthopedic  gymnastics  is  not 
satisfactory  since  the  required  muscle  leverage  is  lacking. 
Fixation  by  bone  graft  is  often  the  only  permanent  means 
of  cure. 

Partial  sacro-iliac  dislocations  may  in  like  manner  re- 
quire bony  fixation  if  the  lesion  is  an  advanced  one. 
Treatment  of  mild  types  of  this  condition  have  been  de- 
scribed under  the  topic  of  sprain. 

Penetrating  Wounds.  Wounds  by  shrapnel,  bayonets 
and  bullets  are  common  in  the  spine.  The  bodies  and  the 
sacrum  do  not  splinter  to  any  extent.  From  the  spinous 
process,  pedicles  or  laminae  splinters  or  chips  of  bone 
may  be  driven  into  the  cord.  The  occurrence  of  paraly- 
sis, which  by  its  type  will  aid  in  localizing  the  injury, 
calls  for  operative  interference.  Use  the  X-ray  for  diag- 
nosis and  reduce  probing  to  a  minimum.  Infected  wounds 
should  be  treated  by  Carrel  or  other  approved  methods 
and  the  fixation  should  be  prolonged. 


Chapteb  Vlii 
CURVATURE  OF  THE  SPINE 

Kyphosis.  This  is  an  abnormal  increase  in  the  dorsal 
curve  of  the  spine  accompanied  by  a  forward  position  of 
the  shoulders  and  head.  With  accompanied  lordosis  it 
gives  us  a  picture  known  as  fatigue  slump.  There  is  a 
type  of  rounded  back,  the  appearance  of  which  is  due  to 
a  heavy  bed  of  muscle  under  and  over  the  scapulae.  The 
pronounced  development  of  the  muscles  beneath  the 
scapulae,  but  more  especially  of  the  supra-  and  infra- 
spinatus, the  rhomboids,  the  trapezius,  teres  major  and 
latissimus  dorsi,  found  particularly  in  heavy-set  athletes, 
rounds  out  the  back.  This  heavy  type  of  muscle  is  often 
found  in  weight-lifters,  wrestlers,  football  players  and 
apparatus  and  gymnastic  team  men,  and  we  find  the  same 
heavy  bed  of  muscles  on  the  chest.  The  need  for  keeping 
such  a  build  in  mind  is  apparent  at  once  in  considering 
the  relationship  between  this  condition  and  corrective 
gymnastics.  Exercises  would  of  course  be  superfluous, 
since  there  is  no  weakness  of  the  upper  back  groups  and 
no  generalized  weakness. 

Obviously  an  incorrect  posture  of  head  and  shoulders 
is  concomitant  with  this  condition  and  when  they  do 
occur  together  the  emphasis  should  be  laid  simply  on  the 
reeducation  of  the  muscle  sense  to  correct  posture.    As 

113 


114  ORTHOPEDICS 

shown  clearly  in  the  studies  made  and  charts  worked  out 
by  the  American  Posture  League,  the  proper  carriage 
without  exaggeration,  of  the  head  erect,  the  shoulders 
back  and  the  abdomen  well  retracted  is  that  position 
which  throws  the  least  strain  upon  those  groups  of  mus- 
cles whose  action  maintains  the  upright  posture.  With 
each  small  increase  in  deviation  from  this  normal  pos- 
ture we  are  subject  to  a  very  great  increase  in  the  effort 
necessary  to  stand  erect.  There  is,  therefore,  due  to  the 
weakening  effect  of  such  unnatural  effort,  a  tendency  to 
further  slumping.  For  instance,  this  fatigue  position 
into  which  a  person  has  fallen  during  the  weakness  of  a 
convalescence  may  of  itself  so  increase  the  strain  of 
standing  correctly  as  often  to  make  it  impossible  for  him 
without  special  treatment  to  reassume  his  former  normal 
posture  even  after  complete  return  to  vigor.  The  con- 
ditions once  assumed  tend  to  become  habitual,  and  due 
to  a  gradually  modified  muscle  sense,  may  be  absolutely 
unconscious  on  the  part  of  the  patient. 

The  two  great  factors  that  determine  the  rapidity  and 
the  amount  of  increase  of  any  postural  defect  are  the 
strain  to  which  the  tissues  of  the  body  are  subject  and 
their  resistance  to  that  strain  as  determined  by  their 
state  of  health  and  development.  In  estimating  the 
amount  of  strain  we  have  to  consider  duration  in  rela- 
tion to  periods  of  rest,  as  well  as  intensity  and  amount. 

Causes.  As  indicated  above,  the  causes  of  this  type 
of  faulty  posture  fall  naturally  into  two  groups.  First, 
where  the  tissues  of  the  body  are  weakened  because  of 
too  rapid  growth,  illness,  faulty  metabolism,  impaired 


CURVATURE  OF  THE  SPINE  115 

mental  development,  overweight.  Children  handicapped 
in  any  of  these  ways  are  affected  quickly  by  undue  strain 
and  we  should  never  lose  sight  of  the  fact  that  the  aver- 
age burden  may  for  them  be  too  great.  The  second  cause 
is  where  normal  children  have  too  great  a  burden  placed 
upon  them.  Among  the  common  strains  to  which  child- 
hood is  subjected,  habitually  assumed  faulty  attitudes  in 
school,  at  home  or  at  work  are  the  most  common.  The 
hanging  of  clothing  from  the  shoulders  where  the  weight 
falls,  as  it  usually  does,  far  out  towards  the  tips,  is  an- 
other cause  for  slumping  forward.  Defects  of  vision  and 
hearing  and  excessive  abdominal  weight  are  also  fre- 
quent causes. 

Symptoms.  The  earliest  symptoms  shown  are  for- 
ward position  of  the  head  and  the  prominence  of  the 
lower  angles  of  the  scapulae,  followed  later  by  a  rolling 
outward  of  their  entire  inner  borders,  with  stretching  of 
the  rhomboid  groups  and  a  forward  position  of  the  shoul- 
der tips.  Up  to  this  point  there  may  be  no  noticeable 
involvement  of  the  spine.  This  slight  amount  of  stoop 
is  not  included  in  kyphosis  by  some  authors.  Some  col- 
lege medical  examiners,  who  do  include  this  degree  of 
faulty  posture  under  the  term  of  kyphosis,  have  reported 
from  sixty  to  eighty  per  cent  of  their  students  as  in  this 
class.  The  next  degree  involves  the  spine  and  it  be- 
comes increasingly  difficult  for  the  patient  on  command 
to  assume  the  normal  posture.  In  fact,  it  is  often  alto- 
gether impossible  for  him.  There  is  a  growing  tendency 
for  the  deformity  to  become  fixed  and  the  spine  less  flexi- 


116  OBTHOPEDICS 

ble.  A  structural  shortening  of  the  pectoral  group  is 
found  in  nearly  all  the  marked  cases. 

Treatment.  By  this  time  the  necessity  for  the  early 
institution  of  the  proper  treatment,  before  the  condition 
has  progressed  far  in  time  or  degree,  must  be  evident 
to  the  reader.  Our  problem  is  not  a  simple  one.  It  in- 
cludes, of  course,  the  removal  of  the  cause,  if  possible,  if 
it  be  of  the  type  we  have  included  under  undue  strain. 
The  general  health  of  the  patient  must  be  built  up  and 
especial  emphasis  laid  upon  this  procedure  where  we 
have  determined  the  cause  to  be  subnormal  strength  due 
to  any  of  the  conditions  mentioned  in  that  group.  '  Our 
corrective  exercises  are  aimed  at  the  particular  group 
of  muscles  whose  relaxed  condition  allows  the  faulty  at- 
titude, here  largely  the  trapezius,  rhomboids,  supra- 
spinatus,  and  the  stretching  out  of  their  physiological  op- 
ponents, with  their  tendency  to  contracture,  in  this  case 
the  pectoralis  major  and  minor  especially. 

There  is  probably  no  type  of  deformity  where  the  use 
of  braces  is  so  much  abused  as  in  this  case.  It  is  well 
to  remind  the  reader  again  that  it  is  only  by  proper  use 
that  muscles  grow  strong,  and  if  the  back  muscles  are 
weak  and  relaxed  and  the  patient  allows  his  shoulders  to 
be  pulled  forward  by  the  stronger  pectorals,  a  brace 
would  but  make  a  bad  matter  worse.  It  would  allow  the 
upper  back  muscles  to  relax  completely  and  to  perform 
a  very  small  proportion  of  their  normal  amount  of  work. 
It  is  evident  that  it  is  their  increased  development  and 
not  their  relaxation  which  we  desire.  These  same  prin- 
ciples apply  to  all  braces  for  the  correction  of  faulty  pos- 


CURVATURE  OF  THE  SPINE  117 

ture.  They  are  as  a  class  not  only  useless  but  often  do 
great  harm.  Their  only  justifiable  use  is  to  prevent 
tissue  relaxation  during  some  temporary  weakness  and 
should  then  be  coupled  with  definite  effort  to  strengthen 
the  affected  parts. 

The  special  fault  to  be  found  with  shoulder  braces  as 
a  class  is  that  they  exert  their  counter  pressure  against 
the  mobile  lumbar  spine  and  tend  to  produce  lordosis.  It 
is  not  unusual  for  children  wearing  such  braces  to  appear 
at  the  dispensary  with  their  shoulders  held  back  but  their 
heads  thrust  forward  and  a  very  pronounced  degree  of 
lordosis  developed. 

EXERCISES 

1.  Comer  exercises.  Child  facing  the  comer  of  the  room 
about  three  feet  in  front  of  it  places  the  hands,  elbow  high, 
against  the  wall  about  a  foot  on  either  side  of  the  corner  and 
the  same  distance  below  the  shoulders.  The  body  is  lowered 
forward  by  bending  elbows,  keeping  the  chin  and  abdomen  re- 
tracted, then  pushed  backward  to  straight  arm.  The  teacher 
standing  behind  resists  the  push  by  exerting  counter  pressure 
with  the  hands  between  the  scapulae. 

2.  Arm — shoulder  groups — using  three  counts. 

(a)  1.  Arms  forward  raise.  2.  Sharply  sideward  carry.  3. 
Sideward  lower — keeping  shoulders  retracted. 

(b)  1.  Arms  forward  raise.  2.  Arms  sharply  forward  bend. 
3.  Sideward  lower — keeping  shoulders  firmly  back. 

(c)  1.  Arms  forward  raise.  2.  Obliquely  side  upward  raise. 
3.  Sideward  lower. 

3.  Knee  bending  at  stall  bars.  Patient  stands  back  to  stall 
bars,  grasps  behind  shoulders,  then  keeping  head,  shoulders  and 
hips  against  the  bars,  does  deep  knee  bend. 


118  ORTHOPEDICS 

4.  Hand  suspension — spine  twisting. 

5.  Pectoral  stretching — supine  on  plinth  or  narrow  bench, 
neck  firm,  counter  pressure  downward  on  elbows. 

6.  Swimming — arms  forward  bend,  lower  trunk  forward,  carrj 
arms  fore  upward  and  slowly  side  downward  in  imitation  of 
breast  stroke. 

7.  Hand  suspension  with  counter  pressure  between  shoulder 
blades. 

8.  Arm  rotation  outward,  forcing  shoulders  back. 

9.  Patient  sitting  on  chair  or  bench,  with  neck  firm.  Teacher 
stands  behind,  knee,  padded  if  necessary,  between  shoulder 
blades,  grasps  shoulders  or  upper  arm,  fingers  in  front,  thumbs 
in  back  and  passively  stretches  the  pectorals. 

10.  Mirror — ^for  reeducation  of  muscle  sense  with  the  aid  of 
sight  to  proper  posture. 

11.  Floor  hang  forward.  Patient  stands  in  back  of  slanting 
ladder  grasping  round,  shoulder  high,  arms  length  in  front. 
"Without  moving  feet  body  sways  forward. 

12.  Wands.  Raise  arms  upward  in  line  with  shoulders. 
Marching  head  erect  with  wand  behind  shoulders.  Thrusting 
upward,  lowering  behind  shoulders,  trunk  lowering  forward. 

Exercises  1,  2,  6,  7,  8, 11,  and  12  are  given  particularly 
for  the  strengthening  of  the  dorsal  muscles. 

Exercises  3,  5,  9  and  11  aim  at  the  stretching  of  the 
pectoral  muscles. 

For  attaining  general  flexibility,  exercise  4  is  espe- 
cially valuable. 

Exercises  6  and  11  should  not  be  used  in  cases  where 
lordosis  also  occurs,  as  their  action  would  tend  to  in- 
crease the  lumbar  curve. 

The  mirror  is  of  particular  value  in  training  muscle 


CURVATURE  OF  THE  SPINE  119 

sense  which  must  be  reeducated  before  the  patient  will 
be  able  to  retain  a  correct  posture. 

Whether  or  not  all  these  exercises,  which  should  be 
done  four  times  each,  are  included  in  an  ideal  program, 
it  must  be  remembered  that  in  the  development  of  tone 
and  reeducation  of  muscle  sense  bodily  tone  must  be 
raised,  the  weakened  groups  of  muscles  must  be  exer- 
cised, the  contracted  muscles  must  be  stretched  and  gen- 
eral flexibility  must  be  attained  so  that  definite  exercises 
for  each  of  these  aims  must  be  included  in  every  pro- 
gram. 

Lordosis.  Lordosis  is  an  abnormal  curve  forward  in 
the  lumbar  spine. 

Occurrence.  Slight  degrees  of  lordosis  are  extremely 
common,  but  such  an  amount  as  will  call  for  treatment  is 
rather  rare. 

Causes.  All  the  etiological  factors  mentioned  for 
kyphosis  may  be  secondary  causes  of  this  condition  since 
lordosis  often  is  secondary  to  and  compensating  for 
kyphosis.  Such  compensation  is  necessary  for  the  rea- 
son that,  with  the  head  and  shoulders  forward,  the  center 
of  weight  transmission  would  fall  too  far  forward  in  the 
lumbar  region.  The  spine,  therefore,  adjusts  itself  by 
increasing  the  lumbar  curve  so  as  to  reestablish  the 
transmission  of  weight  in  the  normal  plane. 

Among  the  primary  causes  are :  1.  High  heels,  which 
increase  the  inclination  of  the  pelvis,  thereby  tilting  for- 
ward the  lower  lumbar  vertebrae  also  and  making  an 
increased  curve  necessary.  2.  Excessive  abdominal 
weight  such  as  the  deposition  of  a  large  amount  of  fat 


\ 


120  ORTHOPEDICS 

in  the  abdominal  wall.  Pregnancy  may  be  a  temporary 
factor.  Poor  or  exaggerated  posture  may  also  bring 
about  this  condition. 

Sequeke.  The  superincumbent  weight  of  the  body, 
the  greater  part  of  which  is  borne  by  the  lumbar  verte- 
brae, tends  greatly  to  increase  this  condition  when  once 
it  has  been  established.  In  addition  the  increased  in- 
clination of  the  pelvis  changes  a  section  of  the  lower 
front  abdominal  wall  from  being  merely  a  retaining  wall 
to  a  weight  bearing  floor  of  the  abdominal  cavity.  The 
abdominal  contents  tend  to  follow  the  relaxed  wall  and 
their  ligaments  exert  an  increased  pull  forward  and 
downward  upon  the  lumbar  spine.  This  condition  in  two 
ways  again  exemplifies  the  fact  that  a  structural  de- 
formity once  established  tends  to  increase  in  degree. 

Treatment.  Braces  are  useless  unless  they  take  their 
fixation  on  the  more  immovable  lower  dorsal  vertebrae 
and  sacrum  and  are  coupled  with  exercise.  If  the  cause 
is  indirectly  due  to  kyphosis,  that  condition  should  be 
treated  at  the  same  time.  General  conditioning  to  re- 
move the  abdominal  weight  must  be  undertaken  and  the 
heels  should  be  lowered  when  these  evils  are  a  part 
of  the  cause. 

EXERCISES 

1.  Long  sitting.  (Legs  extended  forward  on  table  or  floor, 
knees  straight.)     Hold  several  minutes. 

2.  Supine  lying. 

(a)  Alternate  knee  bending  upward. 

(b)  Alternate  leg  raising  forward. 


CURVATURE  OF  THE  SPINE  121 

(c)  Stride  seat  on  plinth  or  narrow  bench.  Raise  wands 
fore — upward  overhead  and  raise  legs  to  long 
sitting  position,  lowering  wand  behind  shoul- 
ders and  return  to  starting  position. 

3.  Hand  suspension. 
Alternate  knee  raising. 

4.  Long  sitting. 

Arms  thrusting  upward  against  counter-pressure. 

5.  Hand  suspension  with  both  knee  raising.  Later  both  leg 
raising,  knees  straight. 

6.  Supine  lying,  feet  fixed — sitting  up  and  returning  to  lying. 

This  last  exercise  can  be  made  increasingly  severe  accord- 
ing to  the  arm  position.  It  is  the  easiest  by  extending  arms 
over  head  and  flinging  them  sharply  with  raising  of  the  body. 
Next,  with  arms  beside  the  body,  then  extended  sideward  or 
folded,  and  hardest,  with  arms  extended  over  head  without  fling- 
ing with  the  body  raising. 

7.  Supine  lying. 

(a)  Bend  both  knees  upward. 

(b)  Raise  both  legs  upward. 

(c)  Flex  and  extend  knees  alternately  in  imitation  of 

bicycle  pedaling. 

8.  Long  sitting — retain  several  minutes. 

Numbers  1,  2,  3,  4  and  8  stretch  the  erector  spinae 
muscles. 

The  others  strengthen  the  abdominal  group  of  mus- 
cles, the  object  of  which  is  to  bring  the  sternum  and  the 
pubis  closer  together,  decreasing  the  inclination  of  the 
pelvis. 

Scoliosis — Rotary  Lateral  Curvature.  One  author  has 
stated  that  ''lateral  curvature  is  the  most  diflficult  and 
subtle  part  of  orthopedic  surgery,"  and  a  survey  of  the 


122  ORTHOPEDICS 

literature  would  certainly  seem  to  confirm  this  state- 
ment. It  is  especially  confused  in  regard  to  the  causes 
of  rotation  and  the  direction  in  which  it  takes  place. 

A  good  deal  of  valuable  research  on  this  subject  has 
been  done  by  Lovett  of  Boston,  Young  of  Philadelphia, 
and  others.  Lovett  especially,  in  his  excellent  book, 
"Lateral  Curvature  of  the  Spine  and  Round  Shoulders," 
devotes  several  chapters  to  the  working  out  of  the  prob- 
lem of  rotation  on  the  living  model  and  the  cadaver.  He 
bases  his  conclusions,  that  the  bodies  rotate  toward  the 
concavity  on  his  experiments  in  functional  lateral  trunk 
bending  on  the  part  of  the  model  and  on  the  torso  of  the 
cadaver,  and  assumes  that  this  applies  equally  to  func- 
tional lateral  curvature.  He  also  states  in  common  with 
other  authors,  that  the  apparent  curve  as  shown  by  the 
marked  spines  is  no  index  of  the  latitude  of  deviation  that 
may  be  present  in  the  bodies — that  the  apparent  curve 
may  be  less  than  the  real  curve.  Most  investigators  be- 
lieve that  the  rotation  is  a  torsion  or  twisting  due  to 
superincumbent  weight.  Following  the  law  that  where 
those  in  the  center  of  a  column  of  block-like  bodies  are 
displaced  so  that  the  center  of  gravity  falls  nearer  the 
periphery  of  some  and  weight  or  pressure  is  exerted  on 
this  column,  those  blocks  displaced  will  twist  upon  their 
vertical  axis,  the  amount  of  turning  being  in  proportion 
to  the  amount  of  displacement.  That  the  spine  follows 
this  rule  is  conclusively  demonstrated  by  Young  in  his 
text-book.  The  bodies  of  the  vertebras  rotate  toward  the 
convexity  of  the  curve,  turning  the  spines  back  toward 


CURVATURE  OF  THE  SPINE  123 

the  mid  line,  thus  making  the  apparent  curve  less  than  the 
real  curve. 

Many  orthopedists  believe  that  the  structural  curves 
are  always  associated  with  softening  of  bone,  and  that 
normal  tissue  may  not  be  deformed.  Recent  operative 
procedures  for  the  correction  of  scoliosis  demonstrate 
that  the  bodies  of  the  vertebrae  rotate  toward  the  con- 
vexity, as  I  have  stated,  and  that  bone  deformity,  espe- 
cially wedge  shaped  vertebraB,  is  not  by  any  means  al- 
ways found  in  rigid  curves,  but  that  these  curves  may 
readily  be  straightened  out,  once  the  muscles  have  been 
dissected  away  and  that  they  are  entirely  responsible  for 
the  apparently  fixed  condition  of  the  curve.  This  is  a 
•still  further  confirmation  of  the  fact  already  stated  that 
muscles,  which  are  given  slack,  tend  slowly  but  surely  to 
a  definite  structural  shortening,  that  may  become  ex- 
tremely resistant  to  corrective  measures. 

Occurrence.  Percentages  given  for  this  defect  differ 
widely,  and  the  acceptance  of  very  slight  degrees  of 
scoliosis  depends  largely  on  the  personal  equation  of  the 
examiner.  Seventeen  per  cent  for  girls,  ten  per  cent  for 
boys  is  probably  a  conservative  estimate  of  the  preva- 
lence of  this  condition. 

Classification.  From  the  standpoint  of  the  condition 
of  the  tissues  involved  scoliosis  may  be  divided  into  func- 
tional, postural  and  flexible,  and  into  rigid,  fixed,  struc- 
tural or  organic.  From  the  standpoint  of  the  appearance 
of  the  curve,  or  curves,  we  differentiate  the  single,  sim- 
ple, total  or  "C  shaped  curves  from  the  compound, 
double  (sometimes  triple)  or  **S'*  shaped  curves.    The 


124  ORTHOPEDICS 

above  classifications  are  not  interchangeable  for,  while  it 
is  perfectly  true  that  most  curves  in  the  beginning  are 
both  single  and  flexible,  single  curves  may  become  fixed, 
or  double  curves  remain  flexible. 

Causes.  It  has  been  stated  that  ''school-rooms  are 
factories  of  scoliosis."  An  exact  knowledge  of  the  me- 
chanics of  proper  school  sitting  is  necessary  if  we  are 
to  decrease  this  defect.  The  following  requirements 
have  been  found  most  satisfactory:  (a)  Height  of  seat; 
feet  should  rest  lightly  on  the  floor,  knees  bent  at  right 
angles,  (b)  Seat  should  slope  slightly  back,  three-eighths 
of  an  inch,  (c)  The  length  of  the  seat  should  be  two- 
thirds  the  length  of  the  thigh,  (d)  The  width  should  be 
at  least  that  of  the  hips,  (e)  The  back  should  slope  back- 
ward about  one  inch  in  twelve  from  the  vertical,  (f) 
The  edge  of  the  desk  should  be  in  a  straight  line  over 
the  edge  of  the  chair,  (g)  The  height  should  be  such 
that  the  forearm  rests  easily  with  elbows  at  right  angles, 
(h)  The  desk  should  slope  back  from  10  to  15  degrees; 
30  degrees  would  be  best  for  seeing,  but  the  books  would 
slide  at  this  angle,  (i)  Pupils  should  sit  back  from  the 
desk  so  that  about  two-thirds  of  the  forearm  rests  on 
it. 

The  large  easy  chair,  often  set  aside  for  the  family's 
young  hopeful,  in  which,  because  of  its  size,  he  is  able  to 
curl  up  and  readily  forms  a  postural  habit,  which  con- 
tinued through  the  years  may  markedly  affect  the  spine, 
is  also  a  cause  to  be  considered.  The  habitual  carrying 
of  all  burdens  on  one  side,  for  example,  newspaper  bags, 
bundles  of  school  books,  hods  of  coal,  etc.,  is  another 


CURVATURE  OF  THE  SPINE  127 

common  cause.  It  is  remarkable  how  soon  children  form 
a  habit  of  carrying  a  given  burden  in  the  same  way,  and 
many  of  them  are  continuously  carried  for  a  number  of 
years.  Shortness  of  one  leg  is  a  frequent  cause.  The 
careful  following  up  of  the  1916  infantile  paralysis  cases 
and  careful  comparison  with  earlier  epidemics  has  led 
many  orthopedic  surgeons  to  the  conclusions  that  this 
disease  is  among  the  very  common  causes  for  scoliosis, 
the  pull  of  the  muscles  on  the  less  affected  side  being  re- 
sponsible. 

Diagnosis.  The  main  reliance  is  placed  on  the  five  fol- 
lowing symptoms:  1.  Unequal  distances  of  the  inner 
border  of  the  scapulas  from  the  spine;  it  is  less  on  the 
convex  side  in  a  dorsal  curve.  2.  The  rhomboid  shaped 
space  between  the  arm  and  the  body,  sometimes  called 
the  arm  waist  angle,  is  less  on  the  side  of  the  curve.  3^ 
Uneven  hips  and  shoulders ;  the  shoulder  tends  to  be  high 
on  the  side  of  the  dorsal  curve.  The  hip  on  the  side  of 
the  curve  in  the  lumbar  region  is  made  prominent.  This 
is  often  mistakenly  called  a  high  hip.  4.  The  marked 
spines  show  the  direction  but  not  the  degree  to  which 
the  vertebras  are  involved.  5.  Prominence  of  one  side  of 
the  back  is  brought  out  by  trunk  bending  forward,  the 
arms  hanging  loosely  and  evenly,  the  Adams'  position. 
Convexity  caused  by  the  prominence  of  the  ribs  is  on  the 
side  of  the  curve  in  whatever  region  it  may  be,  but  it  is 
less  apparent  in  the  lumbar  region.  On  this  sign  alone 
diagnosis  of  functional  curvature  is  justifiable. 

Treatment.    Preventative  treatment  consists   in  the 
study  and  proper  regulation  of  all  habitual  postures, 


128  ORTHOPEDICS 

keeping  in  mind  how  early  such  habits  are  fixed,  and  the 
importance  of  attacking  the  problem  before  faulty  atti- 
tude is  established  Postural  habits  are  corrected  by  fol- 
lowing the  rules  which  apply  to  the  overcoming  of  any 
other  habit,  physical,  mental,  or  moral.  Briefly  they  are : 
1.  To  create  a  clear  cut  picture  in  the  child's  mind  of  the 
correct  posture  from  which  he  habitually  deviates  in 
work,  rest  or  play  with  reasons  if  necessary.  2.  Punish- 
ment, if  necessary,  should  follow  immediately  and  should 
logically  fit  the  misdemeanor.  Here,  then,  it  should  be 
postural  in  type  and,  if  possible,  over-corrective  in  char- 
acter. For  instance,  a  child  with  a  left  total  curvature, 
who  is  told  to  carry  weights  on  the  left  side  and  has  been 
given  the  reasons,  is  discovered  carrying  a  weight  on  the 
wrong  side.  He  should  be  made  at  once  and  under  super- 
vision to  do  some  work  carrying  the  weight  on  the  proper 
side.  3.  Allow  no  exceptions  to  occur.  Relatives,  teacher, 
physical  director,  etc.,  should  all  cooperate  to  see  to  it 
that  the  child  is  reminded  of  every  single  slip.  Patience, 
long  continued,  may  prevent  serious  deformity.  Proper 
food  and  rest  are  all-important  for  the  normal  ossifica- 
tion of  the  bones  and  defects  of  vision  and  hearing  or  the 
shortness  of  one  leg,  or  any  other  contributing  cause 
should  be  remedied. 

Not  only  will  general  strength  and  development  help 
somewhat  in  postponing  the  onset  of  a  scoliosis,  but  they 
are  elements  of  the  tissue  resistance  which  delays  the 
stage  of  structural  deformity  of  the  muscles.  Local 
treatment  consists  of  casts  or  braces  and  exercises. 

Operations.    Bone  fusions  or  graft  operations,  which 


CURVATURE  OF  THE  SPINE  129 

have  recently  been  done  with  what  gives  promise  of  be- 
ing most  brilliant  results  in  selected  cases,  leave  the  pa- 
tient with  a  stiffened  but  straight  spine  in  the  affected 
region.  This  rigidity  is  not  especially  an  undesirable 
feature  since  these  curves  are  all  quite  rigid  in  their 
deformed  position. 

Casts.  Casts  may  be  permanent  or  removable.  Great- 
er correction  and  counter  pressure  is  obtained  by  the 
permanent  cast,  worn  usually  for  about  three  months. 
During  this  time  the  spine  tends  to  increase  its  rigidity, 
musculature  is  weakened  and  the  general  health  often 
slightly  impaired.  The  removable  type  gives  some  sup- 
port, allows  an  opportunity  for  exercising,  but  cannot  be 
applied  to  give  as  great  correction.  Casts  may  be  put  on 
in  the  sitting,  standing,  lying  or  suspended  posture. 
When  adjusted  to  the  patient  lying  supine  one  of  two 
methods  is  employed.  First,  that  advocated  by  Abbott, 
Adams,  Lovett,  and  Bradford  with  the  spine  flexed,  and 
second,  the  method  advocated  by  Whitman,  Schultess  and 
Bucholz  with  the  spine  in  hyperextension.  That  two 
exactly  opposite  positions  of  the  spine  should  be  used 
with  rather  satisfactory  results  in  both  cases  seems  at 
first  difficult  to  explain.  The  principles  involved  are 
these :  The  Abbott  method  aims  at  unlocking  the  articular 
facets,  thereby  unlocking  the  vertebrae  and  making  re- 
rotation  possible.  Since  the  first  effect  of  such  unlocking 
of  the  articulations  is  to  increase  the  rotation,  the  ap- 
parent curve  is  of  course  less,  and  this  fact  has  misled 
some  men  into  thinking  that  the  spine  is  actually  straight 
in  this  position.    It  must  be  remembered  that  a  consid- 


130  ORTHOPEDICS 

erable  amount  of  the  correction  or  overcorrection  force 
obtained  by  this  method  must  be  expended  on  merely  re- 
rotating  the  vertebrae  to  their  former  position  before 
any  net  gain  can  be  secured. 

The  other  method,  that  of  hyperextension,  aims  at  re- 
lieving the  weight  bearing  rotary  strain  upon  the  bodies 
by  shifting  it  backward  upon  the  posterior  part  of  the 
vertebral  column.  This  position  of  course  would  greatly 
aid  in  the  rerotation  of  the  vertebra  bodies,  but  neces- 
sarily more  tightly  locks  the  articular  processes,  which 
in  itself  prevents  rotation.  So  that  any  corrective  effect 
must  act  on  the  column  as  a  whole.  It  is,  not  yet  certain 
which  is  the  better  way.  The  rather  brilliant  results  re- 
ported by  Abbott  have  not  as  a  rule  been  obtained  by 
those  imitating  him. 

The  postural  type  of  scoliosis  very  seldom  requires  a 
cast.  In  fact,  where  constant  exercise  under  supervision 
is  available  there  is  a  tendency  now  to  depend  more  than 
ever  on  active  exercise.  In  any  case  a  period  of  exercise 
for  the  improvement  of  muscle  tone  and  greater  flexi- 
bility should  be  interposed  between  the  casts. 

Various  types  of  braces  and  corsets  widely  advertised 
usually  do  more  harm  than  good.  Successful  treatment 
of  scoliosis  is  not  accomplished  by  the  mail  order  plan. 

In  all  cases  with  marked  softness  of  bone  and  those  of 
rapid  development,  casts  should  always  be  used.  In  situ- 
ations where  exercises  under  good  supervision  are  not 
available  main  reliance  must  be  placed  on  casts. 

Exercises.  Various  corrective  positions,  using  the 
body  weight  to  secure  counter  pressure,  on  various  types 


CURVATURE  OF  THE  SPINE  131 

of  archaic  apparatus  now  collecting  dust  in  the  attics  of 
many  orthopedic  institutions  were  formerly  greatly  re- 
lied upon.  A  glance  through  the  older  text-books  will 
reveal  the  wide  variety  of  this  type  of  armamentarium. 
Active  exercise  on  simple  apparatus  supplemented  by 
counter  pressure  on  the  part  of  the  operator  is  now  used 
almost  exclusively. 

PROGRAMS  OF  EXERCISIS 
I 

Left  Total  Curve. 

1.  Comer  exercise.  Technic  as  described 
for  kyphosis  except  counter  pressure  by 
operator  with  left  hand  on  the  greatest  con- 
vexity on  the  left  side  and  enough  on  the 
right  hip  to  prevent  the  patient  twisting 
to  the  right. 

2.  Stretch  walk  with  self  correction. 
Self  correction  must  be  worked  out  in  each 
individual  case.  Here  it  would  be  with  the 
right  arm  stretched  up,  hand  resting 
lightly  on  the  head,  left  palm  pressing 
against  the  side  as  high  and  as  far  back  as  the  patient  can  place 
it,  the  patient  walking  a  few  steps  usually  on  the  toes  with  active 
attempt  to  stretch  the  spine.  Frequent  periods  of  relaxation  and 
short  periods  of  intense  effort  should  be  insisted  upon. 

3.  Hand  suspension,  spine  twisting.  Hanging  on  horizontal 
bar  or  rings  and  twisting  as  far  as  possible  right  and  left. 

4.  Trunk  bending  left,  hips  fixed,  self  correction  as  above. 

5.  Mirror.  Reeducate  muscle  sense  through  the  eye.  Assist 
patient  to  assume  his  best  possible  posture.  Have  him  walk 
around  the  room,  return  to  mirror  and  correct  any  slump  that 
has  occurred. 


132  ORTHOPEDICS 

6.  Hanging  by  right  arm,  back  to  stall  bar  or  slanting  ladder^ 
left  heel  supported,  right  leg  hanging, 

7.  Trunk  forward  bending  or  lowering,  hips  fixed,  and  rais- 
ing against  counter  pressure  as  in  1. 

8.  Spring  sitting.  Sitting  on  right  side  of  stool  body  in- 
clined forward,  right  arm  reaching  actively  toward  wall  or 
stall  bars,  right  leg  stretched  backward.  Work  arm  and  leg 
toward  the  left,  actively  stretching  the  right  side.  Retain  about 
half  a  minute. 

9.  Hand  suspension,  counter  pressure.  Hang  from  rings  or 
bar,  operator  pushing  patient  forward,  counter  pressure  as  in  1. 

10.  Prone  lying,  feet  strapped,  trunk  raising  backward,  self 
correction  as  in  2. 

11.  Stretching  for  head  plate. 

12.  Floor  hang,  legs  left.  Patient  grasps  horizontal  bar,  stall 
bar  or  rings  about  shoulder  high  and  hangs  down  to  straight 
arm  with  the  feet  well  out  to  the  left. 

13.  Stretch  walk,  balancing  weight  on  the  head. 

14.  Supine  hook  lying — spine  stretching.  Patient  on  table, 
right  knee  over  the  end,  the  right  arm  extended  upward  and 
grasped  by  the  operator  who  stretches  the  right  side. 

15.  Creeping — in  a  circle  to  the  left,  reaching  well  forward 
with  the  right  arm. 

16.  Prone  leg  lying,  trunk  raising.  Patient  lying  prone  with 
waist  at  end  of  table,  feet  fixed,  trunk  flexed  over  end  of  table 
and  raised  upward  to  fullest  possible  extension,  self  correction 
as  in  2.    A  severe  type  of  exercise  for  later  progression. 

17.  Sayre  suspension.  The  addition  of  hip  harness  to  fix 
pelvis,  patient  on  stool,  is  very  efficacious. 

18.  Strap  table — pelvis  and  shoulders  fixed  to  the  left,  one 
or  two  central  straps  fixed  to  the  right,  running  over  the  back, 
under  the  body,  from  which  end  traction  is  exerted  toward  the 
right  and  the  straps  fixed — maintain  ten  minutes. 

A  selection  of  eight  or  ten  out  of  the  above  group,  being 


CURVATURE  OF  THE  SPINE  133 

sure  to  pick  at  least  two  of  each  group  and  reserving  the  others 
for  the  varying  of  the  program  later,  would  be  sufficient. 

We  must  stretch  the  muscles  on  the  concave  side.  This  is 
done  by  exercises  2,  4,  6,  8, 11,  12,  14,  15,  16. 

To  increase  flexibility  exercises,  3,  13,  and  16  are  good. 

Bilateral  strengthening  of  the  back  is  accomplished  by  ex- 
ercises 1,  10,  and  16. 

Rerotation  by  counter  pressure.  Pressure  on  the  convexity, 
on  the  ribs  is  transmitted  to  the  side  of  the  vertebral  body  and 
rerotates  it.  All  the  exercises  in  which  counter  pressure  is 
used,  exercises  1,  7,  9,  and  18  do  this. 

Reeducation  of  muscle  sense  employs  particularly  exercises 
2,  5,  and  13.    Note.    Reverse  each  position  for  right  total  curve. 


Right  Dorsal  Left  Lumbar  Curve. 

1.  Comer — counter  pressure  on  right  dorsal,  left  lumbar  con- 
vexities. 

2.  Stretch  walk  with  self  correction.     Right  hand  on  pos- 
terior axilla,  left  at  the  waist  line. 

3.  Hand  suspension,  spine  twisting. 

4.  Trunk  bending  sideward  toward  principal  curve. 

5.  Mirror. 

6.  Hanging  by  left  arm  at  stall  bar  or  slanting  ladder,  left 
heel  supported,  right  leg  hanging. 

7.  Trunk  lowering  forward,  counter  pressure  as  in  1. 

8.  Spring  sitting,  left  arm  up,  right  leg  back. 

9.  Prone  lying,  feet  strapped,  trunk  raising  backward,  self 
correction  as  in  2. 

10.  Stretching  for  head  plate. 

11.  Stretch  walk,  balance  weight  on  head. 

12.  Supine  hook  lying,  spine  stretching,  right  leg  over  end  of 
table,  traction  on  left  arm. 


134  ORTHOPEDICS 

13.  Prone  leg  lying,  trunk  raising,  self  correction  as  in  2. 

14.  Creeping  with  left  arm  leading  as  much  as  possible  and 
slightly -dragging  the  right  leg,  wide  movements  of  shoulders  and 
pelvis  giving  some  correction  and  increased  mobility. 

15.  Sayre's  suspension. 

16.  Strap  table — ^shoulders  fixed  to  the  right,  hips  to  the  left, 
dorsal  strap  pulled  and  fixed  to  the  left  from  below,  lumbar 
strap  pulled  and  fixed  to  the  right  from  below. 

To  increase  flexibility  3,  11,  14. 

Bilateral  strengthening  1,  9,  13,  15. 

Rerotation  by  1,  7,  8,  16. 

Reeducation  2,  5,  11. 

Note.    Reverse  all  positions  for  left  dorsal  right  lumbar  curve. 

In  both  the  above  programs  there  should  be  progression  in 
the  severity  of  the  exercises  selected  and  the  number  of  repe- 
titions which  might  be  increased  or  varied  from  four  to  ten. 


Chaptbb  IX 
JOINT  INJURIES  AND  ARTHRITIS 

'Anatomy.  Joints  are  formed  by  the  approximation  of 
two  or  more  bones,  whose  surfaces  are  usually  covered 
with  articular  cartilage,  then  with  synovial  membrane, 
moistened  and  lubricated  in  the  healthy  state  by  synovial 
fluid.  In  most  movable  joints,  surrounding  these  struc- 
tures is  a  sleeve-like  capsular  ligament,  reinforced  in  cer- 
tain portions  where  the  strain  is  greatest.  Closely  asso- 
ciated with  many  joints  and  relieving  the  friction  of 
tendons  upon  each  other  and  the  bone,  are  found  closed, 
membranous  sacks  called  bursae,  which  are  partially 
filled  with  synovial  fluid.  The  crucial  ligaments  of  the 
knee  and  ligamentum  teres  of  the  hip  directly  bind  the 
bones  together.  Any  or  all  of  these  structures  may  be 
acutely  or  chronically  injured  by  trauma,  toxins,  or  di- 
rect bacterial  action.  A  common  type  of  trauma  is  slight 
and  long  continued  faulty  posture. 

Classification.  Joints  are  classified  as  immovable  and 
movable,  which  include  sliding,  hinge,  pivotal,  saddle, 
condyloid  and  ball  and  socket.  With  the  first,  as  exem- 
plified by  the  sutures  of  the  skull,  we  are  not  here  con- 
cerned. 

Sprains  and  Dislocations — Traumatic  Lesions.  A 
ftraijLis  often  described  as  the  result  of  the  application 

135 


136  ORTHOPEDICS 

of  force,  abnormal  in  degree  or  direction,  which  does  not 
result  in  an  anatomical  lesion  of  any  of  the  structures  of 
the  joint.  It  would,  therefore,  at  most,  but  temporarily 
weaken  the  function  of  the  joint,  and  would  be  treated,  if 
necessary,  by  the  means  to  be  described  under  sprain. 
\^  A  sprain  is  a  partial  but  immediately  replaced  disloca- 
J  tion,  during  the  process  of  which,  however  brief  in  time, 
there  is  an  actual  tearing  or  other  injury  to  the  tissues 
^  making  up  the  joint.  ^  Tha  symptoms  are  those  of  strain, 
but  considerably  aggravated,  and  include  pain,  swelling, 
sometimes  slight  hemorrhage  and  more  or  less  limitation 
of  function.  The  swelling  is  usually  that  of  increased 
synovial  fluid  and  lymph  within  the  joint,  bursas  or  sur- 
rounding tissues,  nature's  object  being  to  cushion  the 
injured  tissues  with  a  water  jacket  and  so  to  prevent 
further  injury.  Four  undesirable  results  may  follow  here 
and  demand  our  attention.  First,  an  excess  of  fluid  with- 
in the  joint,  as  in  the  case  of  the  knee,  may  so  force  the 
bones  apart  as  to  make  them  unstable  in  a  direction  in 
which,  in  the  normal  state,  because  of  the  bone  forma- 
tion, they  are  not  apt  to  slip.  In  the  joint  named,  the 
tendency  to  lateral  instability  is  the  case  in  point.  Sec- 
ond, a  large  increase  of  fluid  within  the  bursas  or  tissues 
may  make  these  supports  of  the  joint  boggy  and  unse- 
cure.  When  the  fluid  is  finally  absorbed  the  ligaments 
tend  to  remain  relaxed,  as  a  result  of  long  continued 
stretching.  Third,  there  is  a  tendency,  particularly  in 
an  unused  joint,  for  this  fluid  to  become  gummy  and 
gelatinous.  This  may  lead  to  the  formation  of  more  solid 
bodies,  the  so-called  rice  kernels,  within  the  joint.    The 


JOINT  INJURIES  AND  ARTHRITIS        137 

frequent  reinjury,  which  so  often  accompanies  untreated 
cases,  with  retarded  recovery,  may  lead  to  a  thickened, 
doughy  synovial  membrane,  which,  equally  with  the 
coagulated  bodies  just  mentioned,  may  mechanically  in- 
terfere with  the  normal  range  of  movement,  most  com- 
__j]aaaly^f  ound  in  the  knee. 

Finally,  comes  the  formation  of  scar  tissue  or  even 
bone  ankylosis  by  reinjury.  This  reinjury  is  most  apt 
to  occur  during  the  healing  process  unless,  while  under- 
going repair,  the  tissue  is  protected  from  any  movement 
or  position  simulating  that  which  brought  about  the  orig- 
inal lesion. 

In  regard  to  dislocations,  generalizations  only  are  here 
in  order.  For  detail  in  regard  to  each  of  the  possible 
dislocations  of  the  various  joints  the  reader  is  referred 
to  the  section  on  fractures  and  dislocations  and  to  the 
excellent  texts  of  Cotton,  Stimson,  Preston,  Jones  and 
others. 

Dislocation  is  a  complete,  temporary  or  permanent 
change  in  the  relationship  of  the  bones  comprising  the 
joint.  The  surrounding  ligaments  are  always  torn. 
Often  through  the  rent  one  or  more  of  the  bones  ap- 
pear. 

Diagnosis.  Where  the  bony  landmarks  are  all  in  nor- 
mal positions,  where  the  swelling  and  tenderness  are  on 
one  side  of  a  joint,  and  where  gentle  manipulation  can 
be  performed  throughout  nearly  its  normal  range  and 
direction  but  a  given  movement  elicits  more  pain  than 
other  movements,  in  that  joint  we  may  assume  that  we 
are  dealing  with  a  sprain. 


138  ORTHOPEDICS 

Where  there  is  malposition  of  the  bony  landmarks, 
considerable  swelling,  only  a  moderate  amount  of  hem- 
orrhage, where  the  pain  is  diffused  about  the  joint  and 
the  movement  greatly  limited  in  amount  or  direction, 
the  probabilities  are  that  we  have  a  dislocation. 

Where  the  greatest  pain  is  localized  above  or  below  the 
joint,  the  hemorrhage  marked,  the  bony  landmarks 
changed  in  their  relations  and,  except  in  impacted  cases, 
the  motion  increased  and  not  in  the  joint,  a  diagnosis  of 
fracture  is  justifiable.  When  there  is  probability  of  the 
presence  of  either  dislocation  or  fracture,  the  X-ray 
should  always  be  resorted  to  if  possible. 

Treatment.  With  a  clear-cut  impression  of  the  se- 
riou"s"consequences  that  may  follow  untreated  cases  of 
sprain,  it  is  yet  just  as  important  to  remember  that  many 
patients  suffer  from  overtreatment,  or,  better,  over- 
protection,  because  the  fundamental  and  best  of  all  types 
of  treatment,  within  reasonable  limits,  is  use.  This  is 
shown  by  the  fact  that  animals  use  lightly  but  constantly 
such  an  injured  joint,  and  the  rapidity  with  which  it 
usually  heals  is  enlightening.  Hemorrhage  in  this  type 
of  injury,  though  usually  slight,  must  be  considered. 
When  internal  bleeding  has  ceased,  the  use  of  the  joint, 
where  hemorrhage  had  occurred,  is  desired.  It  will  aid 
in  preventicg  the  clotting  of  blood  in  the  tissues  and  in 
quickening  its  absorption.  Use  must  be  differentiated 
from  overuse  or  resprain,  and  can  be  attained  best  by 
means  of  light  or  partial  support,  or  complete  preven- 
tion from  movement  in  an  undesired  direction  or  degree. 
To  cite  again  the  knee  joint,  this  might  be  accomplished 


JOINT  INJURIES  AND  ARTHRITIS        139 

by  the  use  of  a  simple  hinge  brace,  locked  against  over- 
extension and  preventing  any  twisting  or  lateral  devia- 
tion. In  the  ankle  the  common  injury  to  the  external 
lateral  ligament  can  be  properly  supported  by  reversing 
a  flat  foot  strapping,  omitting  the  plantar  straps,  and 
weaving  in  a  few  cross  straps.  If  seen  at  once  an  ap- 
plication of  cold  generally  prevents  excessive  swelling. 
In  all  the  many  and  valued  uses  for  the  various  types  of 
baking  there  is  none  in  which  the  results  are  more  grati- 
fying than  in  its  application  to  these  cases.  Massage 
is  also  of  great  value  and  should,  if  possible,  be  used  in 
combination  with  baking. 

Dislocations  are  reset  at  once  and  treated  as  severer 
sprains  with  emphasis  on  fixation  and  protection.  In  dis- 
locations or  injuries  involving  severe  tears  of  tissue  the 
tendency  to  increase  the  amount  of  adhesion  must  be 
carefully  guarded  against.  Too  early  and  too  violent 
movement  of  the  joint  will  tear  through  the  new  formed 
tissue,  increase  the  inflammation  and  the  amount  of 
fibrous  exudate.  Pain  is  our  main  guide.  It  is  safe  to 
move  the  joint  slowly  as  far  as  we  can  without  eliciting 
severe  pain.  Massage  is  of  great  help  in  increasing  cir- 
culation. Passive  movements  should  be  limited  to  moving 
the  joint  once  through  its  greatest  range  unchecked  by 
pain  and  protective  spasm.  If  it  is  necessary  a  little 
later  the  joint  may  be  moved  once  through  its  entire 
range  under  anesthesia  to  break  adhesions. 

Arthritis.  Traumatic  lesions  of  the  joints  are  de- 
scribed under  sprains  and  dislocations  and  we  are  here 
concerned  with  infective  and  toxic  arthritis. 


140  ORTHOPEDICS 

Toxic  Arthritis.  The  common  diseases  which  often 
manifest  themselves  in  joint  inflammations  are  acute 
articular  rheumatism,  tuberculosis,  gonorrhea  and  syphi- 
lis. Inflammations  of  joint  tissues,  due  to  the  absorption 
of  toxins  from  more  or  less  distant  foci,  are  from  pyor- 
rhea or  abscesses  around  the  teeth,  infected  tonsils,  faulty 
digestion  or  insufficient  intestinal  or  kidney  elimination. 

Acute  rheumatic  arthritis  or  rheumatic  fever  in  the 
acute  and  severe  stage  cannot  be  treated  by  orthopedic 
measures  other  than  support,  but  in  the  mild  or  chronic 
stage  can  be  dealt  with  in  the  same  manner  as  arthritis 
in  general. 

Tuberculous  arthritis  is  treated  first  constitutionally 
following  the  approved  methods  employed  for  arresting 
any  tuberculous  process  in  the  body — rest,  outdoor  living 
and  forced  feeding.  Locally,  by  means  of  brace,  exten- 
sion or  rest  in  bed,  we  attempt  to  immobilize  a  joint  and 
remove  all  weight  bearing  from  it. 

Arthritis  Deformans,  Osteoarthritis,  Rheumatoid 
Arthritis,  Rheumatic  Gout.  Degenerative  and  Prolifera^ 
tive  Arthritis.  Whitman  *  of  New  York,  in  his  treatise 
on  orthopedic  surgery,  has  given  us  perhaps  the  best  brief 
description  of  this  group  of  conditions.  He  says,  **  Under 
these  titles  are  included  a  group  of  chronic  diseases  of 
the  joints  whose  etiology  is  obscure.  At  the  present 
time,  as  these  diseases  are  often  classed  as  varying 
manifestations  of  one  pathological  process,  the  titles  are 
usually  considered  as  synonymous." 

This  group  of  chronic  affections  of  the  joints  are  of 

'Orthopedic  Surgery."  Eoyal  Whitman  (Lea  &  Febiger,  Philadelphia). 


•  m 


JOINT  INJURIES  AND  ARTHRITIS        141 

uncertain  origin,  derangements  of  the  nervous  system 
probably  accounting  for  a  considerable  portion  of  them 
and,  when  present,  are  associated  with  marked  deteriora- 
tion of  the  skin  appendages,  the  hair,  nails,  etc. 

Clinically,  we  have  two  rather  sharply  defined  types, 
hypertrophic  and  atrophic  arthritis. 

Hypertrophic  arthritis  occurs  from  early  adult  life 
through  old  age.  It  is  often  confined  to  one  or  more 
large  joints  but  associated  enlargement  of  the  joints 
of  the  fingers  is  common.  The  synovial  membranes, 
cartilages  and  periarticular  structures  are  all  involved. 
According  to  Da  Costa,  the  changes  begin  in  the  cartilage 
with  a  multiplication  of  the  cells  and  a  degeneration  of 
intercellular  substance.  Wearing  away  of  the  joint* 
cartilage  in  places  brings  pressure  on  the  bones  which 
causes  thinning,  bulging  and  lengthening  by  deposits. 
The  deformity  is  marked  and  the  motion  limited  but 
without  ankylosis.  The  fingers  often  show  Heberden's 
nodes.  The  process  when  located  in  the  spine  produces 
spondylitis  deformans. 

Atrophic  chronic  arthritis  is  largely  a  disease  of  child- 
hood and  early  adult  life.  Its  onset  is  rather  more  rapid 
than  the  hypertrophic  type  and  more  general  in  its  dis- 
tribution. The  joints  become  spindle  shaped;  there  is 
general  muscular  atrophy.  It  is  progressive  in  charac- 
ter and  the  pronounced  destruction  of  cartilage  leads  to 
ankylosis. 

Treatment.  In  no  type  of  arthritis  is  the  constitu- 
tional treatment  of  as  great  importance  as  in  this  condi- 
tion.   Change  of  climate,  particularly  to  one  both  warm 


142  ORTHOPEDICS 

and  dry,  is  beneficial.  Suitable  exercise,  fresh  air,  rest 
and  diet  must  be  provided  for.  Tonics  have  their  plac« 
but  sedative  drugs  must  be  carefully  guarded  against  be- 
cause of  the  long  duration  of  these  joint  affections.  Use, 
within  the  limit  of  strain,  is  to  be  recommended  and 
strain  may  be  guarded  against  by  a  brace  if  desired.  Com- 
plete immobilization  is  only  desirable  for  very  short  pe- 
riods during  acute  exacerbation,  and  prolonged  fixation 
will  but  lead  to  earlier  ankylosis.  Local  treatment  by 
means  of  the  various  forms  of  baking,  massage  and  pas- 
sive movements  are  of  value  in  arresting  the  progress  of 
this  condition.  Operative  interference,  except  for  the 
removal  of  solid  bodies,  or  to  excise  small  joints  is  contra- 
indicated. 

Acute  Rheumatic  Arthritis,  Rheumatic  Fever  or  Acute 
Rheumatism  is  caused  by  a  micro-organism  and  is  char- 
acterized by  high  fever,  multiple  joint  inflammation  and 
predisposition  to  further  attacks.  It  is  often  compli- 
cated by  endocarditis.  The  administration  of  salicylates, 
the  application  of  oil  of  wintergreen,  or  lead  and  opium 
wash  and  the  fixation  of  the  affected  joints  constitute 
the  treatment. 

Acute  arthritis  secondary  to  meningitis,  scarlet  fever, 
etc.,  would  receive  the  same  local  treatment  while  the  dis- 
ease itself  was  being  properly  attended  to. 

Tuberculous  Arthritis.  The  process  starts  first  in  a 
single  joint.    Others  may  later  be  involved. 

Causes.  The  indirect  causes  are  the  lowering  of  local 
resistance  of  joint  structures  as  a  result  of  trauma, 
chilling,  or  chronic  strain.    The  direct  cause  is  the  inva- 


JOINT  INJURIES  AND  ARTHRITIS        143 

eion  of  the  tissues  by  the  tnbercle  bacillus  which  as  a 
rule  first  involves  the  bone. 

Pathology.  It  spreads  from  the  primary  focus  by 
sinus  formation  to  the  synovial  membrane  and  then  to 
the  other  parts  of  the  joint.  Tubercles  form  throughout 
the  joint  structures  which  soften  and  thicken  through 
caseation.  There  is  not  marked  fluid  formation.  This 
process  may  develop  into  sinus  formation  opening  ex- 
ternally with  consequent  danger  of  pyogenic  infection. 

Symptoms.  Swelling  is  usually  not  marked.  Protec- 
tive spasms  of  the  muscles  followed  by  their  atrophy  is 
usually  seen.  Pain  is  often  referred  to  structures  at 
some  distance  from  the  involved  joint,  for  instance,  in 
hip  cases  to  the  inner  side  of  the  knee,  and  in  spinal 
cases  to  the  front  of  the  abdomen.  Finally  the  tissues 
become  matted  together,  the  joint  distinctly  rigid,  the 
skin  white  and  thickened,  the  whole  swelling  spindle 
shaped.  Pain  on  movement  is  a  constant  symptom. 
There  is  danger  of  systemic  involvement  with  the  tuber- 
culous process^ 

Treatment.  Constitutional  treatment  is  the  same  as 
for  other  forms  of  tuberculosis.  Local  treatment  con- 
sists of  fixation  and  extension.  Superheated  dry  air  and 
Bier's  hyperemia  are  helpful.  The  joint  may  be  aspirated 
and  injected  with  iodoform  and  glycerin  when  there  is  a 
large  accumulation  of  fluid.  When  sinuses  are  formed, 
opening  externally,  care  must  be  taken  to  avoid  mixed 
infection.  They  may  be  injected  with  Beck's  bismuth 
paste.  These  conservative  measures  may  prove  suffi- 
cient.   If  a  trial  of  such  treatment  fails  to  improve  the 


144  OETHOPEDICS 

patient,  operation  is  indicated  and  should  be  radical 
and  thorough.  In  cases  showing  amyloid  degeneration 
attempts  at  removing  sequestra  or  forming  bony  anky- 
losis of  fresh  healthy  bone  are  useless  and  amputation 
should  be  resorted  to. 

Gonorrheal  Arthritis.  Gonorrheal  arthritis  is  a  com- 
plication occurring  in  about  two  per  cent  of  the  cases  of 
this  disease.  Its  distribution  in  order  of  frequency  is 
knee,  ankle,  wrist,  shoulder. 

Treatment.  This  is  first  aimed  at  clearing  up  every 
focus  of  infection,  particularly  the  prostate  and  Bartho- 
lin's glands,  and  unless  this  is  thoroughly  done  local 
treatment  is  of  little  avail.  A  large  amount  of  destruc- 
tion may  follow  the  involvement  of  a  joint  and  lead  to 
complete  bony  ankylosis.  In  the  acute  stage  immobilize 
and  counter  irritate  by  heat  or  ichthyol  ointment.  If 
very  severe  aspirate,  irrigate  with  hot  saline  and,  if  joint 
fluid  is  purulent,  incise,  irrigate  and  fixate  with  drainage. 
In  the  subacute  stage  treat  with  baking  or  passive  hy- 
peremia, massage  and  gentle  passive  movements. 

Syphilitic  Arthritis.  Syphilis  of  the  joints  is  rare  as 
compared  to  tuberculosis,  the  diaphysis  of  the  bone  be- 
ing the  part  most  often  attacked.  Hereditary  syphilis 
manifests  itself  during  infancy  as  an  osteochondritis 
which  may  resemble  rickets.  It  is  not,  however,  usually 
bilateral  in  distribution  nor  does  it  usually  involve  more 
than  two  or  three  joints  at  once.  In  older  children  an 
accompanying  periostitis  is  common  and  the  synovial 
membrane  may  be  so  thickened  as  to  interfere  with  nor- 
mal joint  movement.    In  acquired  syphilis  the  joint  may 


JOINT  INJURIES  AND  ARTHRITIS        145 

be  involved  in  the  secondary  and  tertiary  stages.  The 
local  symptoms  are  thickening  of  the  joint  structures  and 
increase  in  its  fluid  with  but  slight  atrophy  of  surround- 
ing muscles.  There  is  pain  on  movement  but  it  is  not 
usually  limited  by  muscle  spasm  and  it  often  persists 
at  night.  Knee,  shoulder  and  elbow  are  most  often  in- 
volved. The  diagnosis  can  be  confirmed  by  the  other  con- 
stitutional manifestations  of  the  disease  and  by  the 
Wassermann  test. 

Treatment.  Local  treatment  consists  in  rest  and  pro- 
tection of  the  joint.  The  constitutional  treatment  is  that 
usually  followed  in  this  disease. 


Chapter  X 
DISEASES  OF  BONES 

Periostitis.  Inflammation  of  the  periosteum  may  be 
acute  or  chronic.  Acute  periostitis  usually  foUows  in- 
jury. There  is  a  local  inflammatory  process,  the  pain 
from  which  is  marked  at  night.  Function  is  interfered 
with.  The  swelhng  is  usually  spindle  shaped  and  may 
be  due  to  a  thickening  of  the  periosteum  and  the  ac- 
cumulation of  fluid  in  or  beneath  it.  A  subperiosteal 
hematoma  may  form.  This  is  sometimes  difficult  to  dif- 
ferentiate from  an  abscess.  The  latter  would,  however, 
give  much  more  marked  signs  of  inflammation,  together 
with  constitutional  symptoms.  The  breaking  down  of 
a  hematoma  through  infection  may  occur  and  should  be 
guarded  against.  Periostitis,  secondary  to  typhoid, 
syphilis,  tuberculosis  and  other  diseases,  is  common,  but 
more  apt  to  be  chronic  in  type  and  to  occur  late  in  the 
disease.  In  syphilis  and  tuberculosis  a  slight  and  un- 
noticed injury  may  lead  to  localized  periostitis. 

Pathologically  the  periosteum  becomes  thickened,  cell 
proliferation  increases  and  there  is  an  extravasation  of 
serum  in  the  tissues.  In  acute  cases  a  discharging  sinus 
may  form  or  the  bone  may  become  soft  through  sclerotic 
condition  of  the  overlying  parts.  In  chronic  cases, 
though  healing  without  the  formation  of  a  sinus,  the 

146 


DISEASES  OF  BONES  149 

calcareous  deposit  within  the  periosteum  of  the  affected 
region  may  cause  a  roughened,  granular  character  of  the 
surface. 

Treatment.  The  most  important  consideration  is  ab- 
solute rest  of  the  diseased  part.  Complete  immobiliza- 
tion and  elevation  should  be  secured.  Swelling  and  ten- 
sion may  be  relieved  by  incisions  to  the  bone  into  which 
several  small  holes  may  be  bored.  In  acute  cases,  where 
septic  conditions  exist,  the  splitting  of  the  periosteum  is 
advocated.  Baking  to  improve  circulation,  and  massage 
to  break  up  granules,  and  remove  excessive  exudate  are 
of  utmost  value. 

Osteitis.  This  condition,  being  usually  secondary  to 
periostitis  or  myelitis,  has  much  the  same  symptoms. 
The  manifestation,  especially  in  tuberculous  cases,  is  very 
slow,  but  pain  and  tenderness  are  more  marked  than  in 
periostitis.  Tucerculous  osteitis  has  been  referred  to 
under  arthritis.  Sequestra,  if  formed  in  the  bone,  should 
be  excised  and  all  operative  procedures,  if  indicated, 
should  be  radical  and  thorough. 

Osteomyelitis.  This  acute  disease  first  starts  in  the 
spongy  ends  or  medullary  cavity  of  the  bone  and  may 
from  there  spread  into  the  joint  or  along  the  shaft.  Its 
onset  is  characterized  by  high  temperature  and  the  gen- 
eral symptoms  of  an  acute  infection.  Suppuration  may 
take  place  and  an  abscess  form.  Periostitis,  which  is 
usually  present,  may  blur  the  picture.  When  this  disease 
occurs  in  the  vertebrae,  the  bodies  may  be  broken  down 
with  subsequent  injuries  to  the  cord.  The  infective  agent 
may  be  ordinary  pyogenic  bacteria,  tuberculous  bacillus, 


150  ORTHOPEDICS 

the  causative  agent  of  typhoid,  syphilis,  measles,  etc.,  or 
by  the  action  of  phosphorus  in  the  body.  Bone  necrosis 
may  follow  rapidly.  The  concurrent  formation  of  new 
bone  by  the  periosteum  may  develop  an  irregular  cortex 
while  the  deeper  layers  of  the  bone  are  being  destroyed. 
Direct  infection  from  infected  wounds,  especially  where 
the  bone  is  shattered  and  the  circulation  impaired,  is 
common.  The  process  has  been  likened  to  gangrene  of 
the  soft  parts.  A  definite  line  of  demarkation  between 
the  sequestrum  and  true  bone  is  often  seen.  The  dead 
bone,  if  small,  is  sometimes  absorbed.  If  not,  it  breaks 
down  and  produces  a  sinus.  Osteomyelitis  is  extremely 
serious,  a  fatal  outcome  being  not  unusual.  Its  early 
diagnosis  is  most  important.  The  X-ray  is  an  invaluable 
aid  in  the  diagnosis  in  the  following  up  of  the  condi- 
tion. 

Treatment.  The  infected  area  should  be  opened  freely 
and  drained.  The  Carrel-Dakin  drip  is  extremely  help- 
ful. Autogenous  vaccines  are  sometimes  of  great  as- 
sistance. Thyroid  medication  is  also  used.  In  case  of  a 
large  amount  of  bone  destruction  all  the  diseased  part 
may  be  removed  and  a  bone  transplant  may  prove  of 
great  assistance. 

Osteomalacia.  Pain  and  muscular  weakness,  similar 
to  conditions  in  rheumatism  or  some  diseases  of  the 
spinal  cord,  are  the  first  symptoms  of  this  disease,  which 
is  most  frequently  found  in  nursing  women,  though  it  may 
occur  in  men  and  even  in  children.  Increasing  deformi- 
ties, chiefly  in  the  spinal  column  and  the  pelvis,  shown 
by  decrease  in  height  and  a  waddling  gait,  are  due  to  the 


DISEASES  OF  BONES  151 

progressive  softening  of  the  bone,  which  can  seldom  be 
arrested.  Slight  injuries  often  cause  fracture,  and  death 
occurs  from  exhaustion  or  disease  of  the  lungs. 

This  condition  may  be  differentiated  from  rheumatism 
by  the  fact  that  the  pain  is  found  in  numerous  plaices. 
Urinalysis  usually  discloses  the  presence  of  calcium  salts 
in  excess. 

As  the  lime  salts  are  removed  the  basement  substance 
remains,  retaining  its  laminated  appearance,  but  further 
progression  may  lead  to  disintegration  and  absorption 
of  this  remaining  substance. 

Treatment.  Improved  hygiene,  tonics,  phosphorus 
and  iodides  are  useful.  When  the  onset  of  the  disease 
is  associated  with  pregnancy,  oophorectomy  is  indicated 
and  further  pregnancy  should  be  avoided.  In  other  types 
Sajous  recommends  epinephrin  injection. 

Tuberculosis.  Tuberculous  disease  of  the  bones  is 
very  largely  confined  to  cancellous  bone.  In  the  long 
bones  it  would  then  make  its  appearance  in  fairly  close 
proximity  to  the  joint  and  from  there  extend  to  the 
periarticular  tissues  and  often  directly  into  the  joint. 

Symptoms  and  treatment  of  tuberculosis  in  these  lo- 
calities have  been  described  under  tuberculous  arthritis. 

Spinal  Tuberculosis.  The  special  manifestations  of 
this  disease  in  the  vertebrae  have  been  described  under 
diseases  and  abnormalities  of  the  spine. 


Chaptee  XI 
FRACTURES  AND  DISLOCATIONS 

THE  UPPER  EXTREMITY 

Clavicle. — Stemo-clavicidar  Joint  Dislocation.  This 
joint  is  dependent  almost  entirely  on  its  ligaments  for 
support.  Its  dislocations  are  forward,  backward  and  up- 
ward, in  order  of  frequency. 

In  forward  dislocations,  the  sternal  end  of  the  clavicle 
is  prominent  and  occasionally  overlaps  part  of  the 
sternum  so  that  the  downward  inclination  of  the  clavicle 
is  increased. 

In  backward  dislocation,  the  prominence  is  less,  and 
there  may  be  congestion  of  the  face  and  neck  on  the  af- 
fected side.  It  is  easily  reduced  by  using  the  arm  as 
a  lever  with  counter  pressure  in  the  axilla,  assisted  by 
deep  respiration  on  the  part  of  the  patient.  Retention 
is  obtained  by  a  molded  pad  and  pressure  with  adhesive 
plaster,  assisted  if  necessary  by  a  posterior  figure  of 
eight  to  hold  the  shoulder  back.  The  arm  is  supported 
in  a  sling. 

Fractures.  Fractures  of  the  clavicle  are  exceedingly 
common.  Its  exposed  position  and  the  fact  that  it  unites 
the  movable  upper  extremity  and  the  trunk  are  the  rea- 
sons for  its  frequent  fractures.  At  its  inner  aspect,  the 
attached  fibers  of  the  sterno-mastoid  muscle  pull  upward 

152 


FRACTURES  AND  DISLOCATIONS         153 

and  the  pectoralis  major  downward,  but  the  direct  pull 
of  the  former  is  nearly  at  right  angles  to  the  bone,  that 
of  the  latter  more  nearly  parallel  to  it.  The  pull  of  the 
stemo-mastoid  is,  therefore,  stronger  and  the  inner  frag- 
ment is  usually  displaced  upward.  On  the  outer  third 
of  the  bone,  the  antagonistic  pull  of  the  deltoid  and  the 
trapezius  are  nearly  equal  and  displacement  is  not  usually 
marked. 

Symptoms.  Pain,  loss  of  function,  and  change  of  nor- 
mal outline  immediately  follow. 

Treatment.  Reduce  by  traction  on  the  shoulder,  out- 
ward, backward  and  upward  and  retain  by  a  permanent 
dressing.  The  modified  Velpeau  bandage  or  Sayre*s 
dressing  is  good.  In  children,  the  Taylor  brace  and  the 
brace  devised  by  Crane  of  Waterbury  are  both  useful.  All 
of  these  dressings  need  constant  care  and  adjustment 
to  take  up  slack  and  keep  the  part  secure. 

Acromio-clavicular  Joint  Dislocation.  The  joint  is 
covered  by  the  superior  and  inferior  clavicular  and  the 
coraco-clavicular  ligaments,  the  deltoid  muscle  in  front 
and  the  trapezius  behind  adding  their  support.  Dislo- 
cation of  the  clavicle  upward  is  the  common  injury. 

Symptoms.  Pain  in  the  joint,  moderate  loss  of  func- 
tion, prominence  of  the  outer  end  of  the  clavicle,  and 
sometimes  prominence  of  the  tip  of  the  scapula  are  evi- 
dent. Sir  Robert  Jones  uses  a  simple  sling  for  the  wrist 
and  then  binds  down  a  small  pad  on  the  tip  of  the  clavicle 
by  a  bandage  passed  under  the  elbow  and  knotted  firmly 
on  the  shoulder. 

Scapula. — Fractures.    The  heavy,  springy  bed  of  mus- 


154  ORTHOPEDICS 

cle  nearly  surrounding  the  scapula  makes  it  extreinely 
difficult  to  fracture  this  bone.  The  spine  and  acromion 
process,  being  more  exposed,  are  occasionally  fractured. 
Separation  of  the  acromial  epiphysis,  which  unites  quite 
late,  may  be  mistaken  for  fracture.  The  fracture  may  in- 
volve the  coracoid  process,  the  glenoid  cavity,  or  the 
body  below  the  spine. 

Symptoms.  Loss  of  function,  pain  increased  by  deep 
respiration  and  crepitus  are  noted.  X-ray  is  often  neces- 
sary to  ascertain  the  extent,  since  crepitus  may  be  lack- 
ing. In  the  treatment,  prevent  muscular  pull  or  move- 
ment of  the  fragment  and,  if  the  body  is  affected,  im- 
mobilize the  scapula  as  a  whole  by  strapping,  Velpeau 
bandage  or  cast.  Maintain  from  four  to  six  weeks.  Com- 
plete return  of  function  is  the  rule. 

Shoulder.  Surgical  Anatomy.  The  shallow  socket, 
large  variety  of  movement,  and  exposed  position  of  the 
shoulder  joint  make  it  the  most  frequent  seat  of  dislo- 
cation. The  coracoid  and  acromion  processes  of  the 
scapula  and  their  ligaments,  while  not  entering  into  the 
joint  proper,  protect  it  from  above  and  prevent  upward 
dislocation,  making  this  type  the  rarest  of  all.  Mobility 
being  of  prime  importance,  the  socket  is  very  shallow  and 
stability  is  dependent  largely  upon  the  muscles  and  ten- 
dons. The  capsular  ligament  entirely  encircles  the  joint 
from  the  rim  of  the  glenoid  cavity  to  the  anatomical  neck 
of  the  humerus.  It  is  quite  lax  and  is  put  upon  a  tension 
only  at  the  limit  of  arm  movement  in  the  various  direc- 
tions. Muscle  tone  alone  keeps  the  joint  surfaces  in  ap- 
position and  the  deltoid  is  mainly  responsible  for  this. 


Fk;.  o'.t.     ('.vnoT  I'o.stkuioh  Lki;  Sim. int. 
[X-Ray  (Fig.  38)  shows  injury  to  external  condyle. 

Fig.  40.    Airplane  Splint  with  Elbow  Joint. 


FRACTURES  AND  DISLOCATIONS         157 

The  brachial  plexus  and  vessels  lie  just  internal  to  the 
head.  In  injury  the  capsular  ligament  is  always  torn 
and  more  or  less  harm  is  often  done  to  the  tendons  over- 
lying it. 

Dislocations.  In  spite  of  the  variety  of  directions 
which  the  head  may  take,  the  following  classification  is 
suflScient : 

-    -c  J       f  Subcoracoid.    (Most  common.) 

1.  Forward.        o  i,  i     •     i 

[  Subclavicular. 

2.  Do^-nward.  I  Subglenoid.    (Very  common.) 

[  Subglenoid  erecta. 

o   -D    V.       J    { Subacromial.    (Fairly  common.) 
I  Subspinous. 

4.  Upward.         (Uncommon.) 

Subcoracoid.  The  head  lies  just  below  the  coracoid 
process,  tearing  the  anterior  and  inferior  part  of  the 
capsule.  The  humerus  is  rotated  inward ;  the  subscapu- 
laris  tendon  is  sometimes  torn.  Extreme  degrees  become 
subclavicular. 

Subclavicular.  In  this  type  the  head  is  further  in- 
ward and  slightly  higher  and  all  the  structures  are  more 
lacerated.  Kocher's  method  of  reduction  is  inefficient. 
We  get  a  flattening  and  sharpening  of  the  shoulder;  the 
anterior  axillary  fold  is  lower;  the  elbow  is  abducted 
and  the  head  of  the  humerus  lies  beneath  the  coracoid 
process.  It  is  hard  to  place  the  hand  on  the  uninjured 
shoulder  as  the  arm  cannot  be  abducted.  The  patient 
leans  toward  the  injured  side  and  usually  allows  the  arm 
to  hang  when  he  is  standing. 


158  ORTHOPEDICS 

Treatment.  Subcoracoid  dislocation  is  most"  easily 
reduced  by  Kocher's  method,  the  three  main  manipula- 
tions of  which  are:  1.  The  surgeon  standing  in  front, 
grasps  the  patient's  elbow  with  his  opposite  hand  and 
holds  it  against  the  side,  grasping  the  wrist  with  his 
other  hand.  The  elbow  is  flexed  to  a  right  angle  and  the 
arm  rotated  externally.  2.  The  elbow  is  brought  gently 
inward  across  the  chest,  the  hand  remaining  fixed.  Slight 
force  may  be  used  several  times  if  necessary  and  the  head 
slips  into  the  glenoid  cavity  with  a  distinct  sound.  The 
third  manipulation  should  not  be  attempted  until  this 
has  happened,  as  replacement  usually  occurs  at  this  point. 
3.  This  consists  in  rotating  the  arm  inward,  bringing  the 
hand  toward  the  opposite  shoulder. 

Another  method  is  by  horizontal  abduction  and  manipu- 
lation with  surgeon's  knee  or  flexed  thigh  under  the  axilla 
while  an  assistant  exerts  traction  on  the  arm.  It  is  of 
further  advantage  to  have  the  scapula  fixed.  Slight 
swinging  or  rotating  of  the  arm  will  aid  reduction. 

Subglenoid.  The  head  escapes  through  the  inferior 
and  posterior  fibers  of  the  capsule,  resting  below  the 
acromion  process  or,  in  the  subspinous  variety,  further 
back  under  the  spine  of  the  scapula. 

The  shoulder  is  flattened ;  the  head  cannot  be  palpated 
in  its  normal  position,  but  below  the  acromion  process; 
the  humerus  is  rotated  inward  and  is  held  in  adduction. 

Treatment  by  Kocher's  method  may  be  successfully 
employed,  but  in  the  first  movement  the  elbow  should 
be  farther  back  to  approximately  the  mid-axillary  line. 
Reduction  may  be  obtained  by  traction  accompanied  by 


FRACTURES  AND  DISLOCATIONS         161 

slight  rotation  and  adduction.  Operative  treatment 
should  never  be  necessary  in  uncomplicated  cases. 

After  treatment.  Immobilize  for  several  days  to  facili- 
tate repair  and  carry  arm  in  sling,  but  forbid  abduction. 
Allow  slight  active  movements  during  the  second  and 
third  weeks  and  obtain  complete  abduction  by  the  exer- 
cises described  for  this  desired  result,  the  patient  lying 
prone.  Common  complications  are  fracture  of  the  sur- 
gical neck;  associated  dislocation  is  rare.  It  should 
be  treated  by  the  open  method  and  the  use  of  McBurney's 
hook  to  replace  the  head.  Fracture  of  the  anatomical 
neck  is  still  more  rare.  Here  the  head  should  be  wired, 
or,  if  it  cannot  be  replaced,  excised.  Fracture  of  the 
greater  or  lesser  tuberosity  should  be  wired  unless  it  is 
possible,  after  setting  the  dislocation,  to  abduct  and  ex- 
ternally rotate  the  arm  without  redislocation.  Bone 
pegs  and  screws  are  sometimes  used. 

Fracture  of  the  neck  of  the  scapula  leaves  a  movable 
joint.  The  arm  is  easily  adducted;  the  whole  shoulder 
dropped.  The  elbow  is  raised  and  retained  by  a  fixating 
bandage. 

Recurring  dislocations  are  treated  by  operation  with 
repair  of  the  rent  and  occasionally  tucks  taken  in  the 
relaxed  capsular  ligament. 

Fractures  op  the  Humerus.  Fracture  of  the 
Anatomical  Neck.  The  line  of  fracture  seldom  follows 
the  anatomical  neck  exactly ;  often  the  greater  tuberosity 
is  included.  Impaction  and  the  separation  of  fragments 
are  common,  especially  in  the  aged.    There  are  pain,  swell- 


162  ORTHOPEDICS 

ing  and  hemorrhage,  but  the  head  is  in  place ;  crepitus  is 
not  easily  obtained ;  the  shortening  is  not  great. 

When  firmly  impacted  do  not  attempt  to  disengage. 
Bind  the  arm  with  a  modified  Velpeau  bandage,  using  a 
triangular  axillary  pad.  Massage  is  begun  early,  passive 
movements  late ;  three  weeks  at  least  should  elapse.  Ab- 
duction is  then  obtained  in  the  prone  lying  position  or 
with  overhead  pulley  weights.  Several  of  our  patients 
have  done  extremely  well  when  put  up  in  a  plaster  in 
extreme  extension  for  five  weeks,  followed  by  massage 
and  passive  movements. 

Fractures  of  the  Surgical  NecTc.  A  great  tendency  to 
displacement  is  manifest  in  these  fractures.  The  lower 
fragment  is  usually  drawn  toward  the  body,  rotated  in- 
ternally and  often  elevated  by  the  action  of  the  deltoid 
and  biceps.  This  is  best  treated  by  traction  made  on  the 
arm  in  the  line  of  its  long  axis  with  abduction  and  out- 
ward rotation.  The  abduction  should  be  carried  to  an 
oblique  side-upward  plane.  In  this  position  traction 
corrects  the  overriding  and  accurate  setting  is  possible. 
When  secured  the  arm  may  then  be  lowered  gently  and 
with  great  care,  the  elbow  flexed  to  less  than  a  right 
angle  and  the  arm  fixed  in  this  position.  When  displace- 
ment tends  to  reoccur  the  arm  should  again  be  abducted 
as  described  and  fixed  in  that  position  in  a  cast.  The  fore- 
arm should  be  included  to  insure  external  rotation  and 
may  rest  easily  behind  the  head. 

The  unavoidable  formation  of  adhesions  after  any  of 
these  injuries,  should  be  treated  as  described  in  arthritis 
of  the  shoulder  as  soon  as  repair  is  complete. 


FRACTURES  AND  DISLOCATIONS         165 

Ankylosis  of  the  Shoulder.  Where  this  complication 
is  inevitable  Jones  gives  the  following  directions  for  ob- 
taining the  most  useful  position  for  the  shoulder  joint. 
He  says : '  *  First,  the  arm  should  be  abducted  about  sixty 
degrees  or  more  from  the  side,  movement  of  the  scapula 
will  easily  replace  the  amount  of  abduction.  Second, 
the  arm  should  be  rotated  out  far  enough  for  the  hand 
to  be  brought  to  the  back  of  the  head  when  the  shoulder 
is  raised.  Third,  the  elbow  should  be  a  little  in  front 
of  the  mid-axillary  hue,  for  convenience  in  handling  table 
implements,  etc. 

*'If  these  three  points  are  attended  to  during  the  treat- 
ment of  an  injury  of  the  shoulder  in  which  ankylosis  is 
inevitable,  the  muscles  about  the  scapula  will  soon  learn 
to  increase  their  range  of  movement.  To  hasten  this  the 
patient  should  assiduously  practice  all  possible  move- 
ments of  the  arm. 

**A  patient  with  an  arm  ankylosed  in  this  position  can 
perform  all  ordinary  movements  so  unobtrusively  that 
many  people  will  fail  to  observe  he  has  any  limitation 
of  movement  at  the  shoulder.  * ' 

Fractures  of  the  Shaft  of  the  Humerus.  The  wide 
range  of  movement  obtained  by  this  bone  makes  it  sub- 
ject to  a  great  variety  of  types  of  trauma.  Single,  trans- 
verse or  oblique  through  and  through  fractures  are  the 
usual  types.  The  close  apposition  of  the  musculospiral 
nerve  makes  it  especially  prone  to  direct  injury  or  to 
later  compression  by  the  formation  of  a  callus. 

These  fractures  are  usually  easily  recognized  by  the 
deformity,  shortening,  hemorrhage,  point  of  abnormal 


166  ORTHOPEDICS 

mobility  and  crepitus.  Treatment  will  vary  according 
to  the  degree  and  amount  of  displacement.  Simple  trac- 
tion and  manipulation  will  usually  realign  the  fragments 
though  anesthesia  may  be  necessary.  Fractures  are 
put  up  in  the  same  manner  as  those  of  the  upper  end  with 
the  triangular  pad  in  the  axilla,  splint  or  plaster  sup- 
port and  bandage  to  include  the  body.  A  protecting  cap 
of  plaster  over  the  shoulder  or  entire  arm,  including  the 
elbow,  is  of  great  service. 

In  the  operative  treatment,  the  fixation,  which  is  occa- 
sionally necessary,  may  be  secured  by  bone  pegs,  screws, 
wire  or  the  Lane  plate. 

Fractures  of  the  Lower  End  of  the  Humerus. — Surgi- 
cal Anatomy.  Preston,  in  his  description  of  the  surgical 
anatomy,  says:  "The  lower  end  of  the  humerus  articu- 
lates with  two  bones ;  the  types  of  these  articulations  are 
entirely  different  and  the  fractures  occurring  in  this  re- 
gion are  complex.  The  lower  end  of  the  bone  curves 
forward  and  is  flattened  from  before  backward.  The 
articular  surfaces  may  be  described  roughly  as  a  cylinder 
mounted  on  the  lower  end  of  the  shaft,  with  the  axis  of  the 
cylinder  nearly  transverse  to  the  long  axis  of  the  shaft. 
The  outer  end  of  the  cylinder  is  at  a  slightly  higher  level 
than  the  inner  end.  When  the  elbow  is  fully  extended  the 
arm  and  forearm  are  not  in  the  same  straight  line,  but 
form  an  angle  of  about  170  degrees,  half  of  which  is 
caused  by  the  obliquity  of  the  articular  surfaces  of  the 
lower  end  of  the  humerus,  while  the  other  half  is  the 
result  of  the  position  of  the  bones  of  the  forearm.  In 
complete  extension,  therefore,  we  have  the  "carrying 


FRACTURES  AND  DISLOCATIONS         167 

angle'*  while  in  complete  flexion  the  forearm  comes  in 
contact  with  and  folds  directly  upon  the  arm.  When 
the  fragments,  in  fractures  of  the  lower  end  of  the 
humerus,  are  allowed  to  unite  in  deformity,  there  may  be 
a  disturbance  in  the  carrying  angle  which  is  apparent 
when  the  arm  is  extended,  and  in  addition  there  may 
also  be  a  deformity  in  which  the  forearm  does  not  fold 
directly  against  the  arm  in  acute  flexion.  The  carrying 
angle  varies  considerably  in  different  individuals  and  the 
examination  should  therefore  include  comparison  with 
the  uninjured  elbow. ' '  * 

Types  of  these  fractures  are  commonly  transverse 
above  the  condyles  or  through  them.  Either  of  the 
condyles  may  be  fractured ;  that  of  the  external  often  in- 
cluding the  capitellum  and  the  internal,  the  trochlea. 
Fractures  of  the  capitellum  by  indirect  violence,  separa- 
tion of  the  epiphysis,  Y  or  T  shaped  fractures  into  the 
joint  are  commonly  noted  fractures  with  extensive  in- 
volvement of  the  lower  end  of  the  humerus. 

All  of  these  fractures,  except  those  of  the  olecranon, 
are  put  up  with  the  elbow  in  extreme  flexion.  Olecranon 
fractures  require  extension. 

Impairment  of  function  is  almost  certain  to  follow 
incomplete  reduction  or  large  callus  formation. 

Supra-condylar  Fractures.  When  by  direct  or  indi- 
rect violence  the  lower  fragment  is  displaced  backward, 
reduce  by  flexion  and  downward  traction  on  the  fore- 
arm.   Put  up  fully  flexed  to  prevent  callus  formation. 

•Preston,  "Fractures  and  Dislocations,"  Mosby  Company,  St.  Louis. 
Page  120. 


168  ORTHOPEDICS 

Reduce  the  extent  of  the  flexion  slightly  after  a  few  days, 
reaching  the  right  angle  in  about  ten  days.  Passive  and 
active  movements  used  early  should  be  confined  to  the 
range  of  movement  between  semi-  and  full  flexion. 

Epicondylar  Fractures.  Fractures  of  the  epicondyle 
not  involving  the  joint  or  the  capitellum  are  rare.  There 
is  swelling  and  tenderness  of  the  external  condyle.  The 
fragment  is  not  usually  much  displaced. 

Epitrochlear  Fractures.  In  this  type  there  is  separa- 
tion of  the  internal  epicondyle  not  involving  the  joint 
or  the  trochlea.  The  symptoms  are  tenderness,  pain  and 
hemorrhage  along  the  inner  side  of  the  arm.  Flexion 
and  extension  of  the  elbow  are  not  usually  painful  ex- 
cept at  their  extreme  limits. 

Feactuees  Involving  the  Joint. — Fracture  of  the  Ex- 
ternnl  Condyle.  This  includes  the  capitellum,  is  quite 
common  and  the  symptoms  resemble  epicondylar  frac- 
ture but  are  much  more  severe.  There  are  almost  total 
loss  of  function,  severe  pain  and  marked  swelling.  The 
joint  is  very  unstable  from  side  to  side  and  may  be  moved 
freely  in  this  direction ;  crepitus  is  usually  present.  The 
deformity  is  described  as  * '  gunstock. '  *  The  fragment  is 
displaced  downward  and  greatly  turned. 

Fractures  of  the  Internal  Condyle.  The  break  ex- 
tends through  the  trochlea.  The  same  symptoms  of  pain, 
swelling,  hemorrhage  and  crepitus  are  present  on  the 
inner  side;  the  same  lateral  mobility  is  found. 

Y  shaped  or  comminuted  fractures  may  partake  large- 
ly of  either  or  both  of  the  sets  of  symptoms  just  described 
and  are  produced  by  the  force  of  a  blow  transmitted 


FRACTURES  AND  DISLOCATIONS         169 

through  the  olecranon  and  splitting  the  humerus.  There 
may  be  backward  displacement  of  the  elbow,  but  the 
olecranon  is  uninjured. 

Treatment.  The  surgeon  grasps  the  back  of  the  el- 
bow with  one  hand,  the  wrist  with  the  other  and  exerts 
traction  on  the  wrist  until  the  forearm  returns  to  its 
normal  alignment.  The  elbow  is  then  fully  flexed.  Some 
force  may  be  required,  as  it  may  necessitate  pushing  back 
fragments  which  have  been  displaced  forward.  The 
hand  behind  the  elbow  can  aid  this  replacement.  Com- 
plete flexion  is  absolutely  essential. 

After  Treatment.  Jones  gives  a  simple  rule  for  the 
protection  of  any  injury  about  the  elbow  from  too  early 
movement.  It  is  that  the  absence  of  tenderness  about 
the  elbow  indicates  that  it  is  ready  for  the  second  test, 
which  is  the  lengthening  of  the  sling  and  allowing  the 
wrist  to  drop  three  inches.  After  two  days,  if  the  pa- 
tient is  able  actively  to  flex  the  elbow  fully,  he  may  re- 
peat the  exercise  to  full  extension  daily.  If,  on  the  other 
hand,  the  elbow  becomes  stiff  by  protective  spasm,  it  is 
an  index  that  this  procedure  is  premature  and  the  elbow 
should  be  put  up  in  full  flexion  for  another  week.  He  ad- 
vises against  the  use  of  the  right  angle  internal  splint  for 
the  elbow. 

Fractures  of  the  Olecranon.  Fracture  may  be  of  the 
tip  only  or  a  large  part  of  the  process.  If  there  is  no 
displacement  of  the  fragment  upward  a  pad  placed  above 
and  an  anterior  splint  with  the  arm  fully  extended  should 
secure  firm  union  in  two  or  three  weeks. 

Fractures  involving  marked  displacemnt  by  the  ao- 


170  OETHOPEDICS 

tion  of  the  triceps  should  be  fixed  by  wire,  peg  or  kan- 
garoo tendon  and  then  treated  as  indicated.  Care  must 
be  taken  not  to  injure  the  epiphysis  in  children  and  it  is 
sometimes  wiser  even  with  displacement  to  use  the  for- 
mer method.  In  cases  of  elderly  persons  sufficient  func- 
tion can  usually  be  obtained  by  extension  and  the  pad. 

Dislocation  of  the  Elbow.  Dislocations  may  be  back- 
ward, which  are  very  common;  outward,  which  are  also 
common;  inward  and  forward,  which  are  rare. 

Surgical  Anatomy.  The  radio-humeral  joint  is  of  the 
condyloid  variety,  while  the  ulnar-humeral  is  a  hinge 
joint.  The  internal  lateral  ligament  is  divided  into  a 
strong  anterior  and  posterior  band,  as  is  also  the  ex- 
ternal lateral  ligament.  Overextension  of  the  elbow  is 
prevented  by  the  anterior  segments  of  the  lateral  liga- 
ments, the  anterior  fibers  of  the  capsular  ligament  and 
the  checking  of  the  tip  of  the  olecranon  at  the  olecranon 
fossa.  Overflexion  is  prevented  by  resistance  of  the 
lower  part  of  the  biceps  to  the  forearm  and  by  the 
coronoid  process  checked  by  the  coronoid  fossa. 

Backward  Dislocations.  The  forearm  is  held  almost 
in  extension;  the  tip  of  the  olecranon  is  above  its  usual 
plane  and  more  prominent ;  the  forearm  is  shortened ;  the 
triceps  tendon  is  prominent.  The  coronoid  process  is 
behind  the  trochlea,  the  whole  forearm  rotated  slightly 
inward,  the  head  of  the  radius  behind  the  capitellum. 
The  same  pain,  immobility  and  swelling  which  occur  in 
other  dislocations  are  of  course  present.  We  treat  by 
hyperextension  and  traction  enough  to  clear  the  coronoid 


Fig.  45.    Extensive  Shrapnel  Wouxd  of  Right  Arm  with  Compound  Com- 
minuted Fracture  of  Humerus. 

Some  union  with  beginning  necrosis  of  loose  fragment  metallic  body  4x6  mm. 
in  front  of  injury. 

Fig.  46.    Machine-gun  Bullet  Through  Condyles  of  the  Left  Humerus. 
Treated  by  removable  cast    February  6,   1919.     Elbow  nearly  ankylosed 
only  five  degrees  of  movement  in  flexion.    Four  weeks  of  treatment  increased 
this  range  to  forty  degrees. 

Fig.  47.    Old  Infected  Gunshot  Wound  of  Upper  End  of  Right  Radius  and 
Ulna  Involving  Elbow  Joint. 
Elbow  ankylosed. 


FRACTURES  AND  DISLOCATIONS         173 

process,  and  then  fixation  in  complete  flexion  for  two  to 
three  weeks  is  necessary. 

Lateral  Dislocations.  These  dislocations  are  rare  and 
can  usually  be  reduced  by  flexion  of  the  forearm  and  ex- 
tension of  the  arm,  but  an  anesthetic  may  be  necessary 
to  thoroughly  relax  the  muscles. 

Forward  Dislocations.  This  type  is  very  rare  except 
with  olecranon  fracture.  Reduction  is  accomplished  by 
flexing  the  forearm  and  exerting  traction  under  anes- 
thesia if  necessary. 

Myositis  Ossificans  Traumatica.  Improvement  in 
X-ray  technique  is  revealing  this  as  a  rather  common 
sequela  of  elbow  dislocation,  especially  of  the  backward 
type.  Torn  tags  of  periosteum  with  its  osteo-genetio 
power  probably  start  the  ossification  process.  No  known 
means  of  arresting  or  curing  this  condition  are  available 
but  its  prevention  can  to  some  extent  be  obtained  by  the 
earliest  possible  reduction  and  the  limitation  of  trauma 
both  then  and  later.  Too  early  passive  and  active  move- 
ments should  be  avoided.  The  onset  and  progress  of 
the  condition,  if  it  occurs,  is  followed  by  means  of  the 
X-ray.  It  is  well  to  warn  the  patient  of  the  possibility 
of  this  complication  and  against  too  early  vigorous  use 
of  the  arm. 

Dislocation  of  the  Radial  Head.  The  orbicular  liga- 
ment is  always  torn.  Press  the  head  of  the  radius  back 
into  place,  flex  fully  with  the  forearm  completely  supinat- 
ed,  place  pad  over  the  radial  head  and  bandage  firmly. 

Ankylosis  of  the  Elhoiv.  Where  it  is  necessary  to  fix- 
ate the  elbow  joint  it  should  be  done  at  just  about  forty* 


174  PHYSICAL  RECONSTRUCTION 

five  degrees,  as  the  weight  of  the  arm  may  in  time  slightly 
increase  the  angle  to  about  fifty  or  fifty-five  degrees. 

Wounds  of  the  Elhow  Joint.  There  has  been  a  large 
proportion  of  septic  wounds  in  the  present  war,  many  of 
them  causing  a  marked  amount  of  destruction  of  joint 
tissue.  An  extension  wire  splint,  which  will  allow  the 
wound  to  be  dressed  without  disturbing  the  joint,  the 
Carrel-Dakin  drip  and  the  use  of  passive  movements 
when  the  inflammation  has  entirely  subsided,  are  achiev- 
ing splendid  results. 

Fractures  of  the  Head  of  the  Radius.  The  head  is 
displaced;  crepitus  may  be  obtained  by  pronating  and 
supinating  the  hand,  the  head  not  rotating  with  the  shaft. 
This  sign  is  absent  in  impacted  cases.  The  biceps  may 
pull  the  upper  fragment  forward.  The  pressure  pad 
should  be  placed  over  the  upper  fragment  and  the  arm 
should  be  fised  in  moderate  flexion.  In  fractures  near  the 
head  acute  flexion  without  the  pad  is  better.  In  com- 
minuted fractures  of  the  head  operation  is  indicated. 
After  treatment,  dressing  should  be  tightened  as  the 
swelling  decreases  and  should  be  kept  on  from  three  to 
five  weeks. 

Fractures  of  the  Shaft  of  the  Radius.  There  may  be 
a  concavity  over  the  point  of  fracture  when  the  frag- 
ments are  displaced  toward  the  ulna.  Crepitus  can  usu- 
ally be  elicited.  The  greenstick  fracture  is  the  rule  in 
children  and  a  slight  bulging  or  depression  may  be  the 
only  sign  besides  the  localized  pain. 

Fracture  of  the  Ulna.    Symptoms  are  similar  to  the 


Figs.  48  &  49.    Compouxd  Comminuted  Fracture,  Oblique  of  Radius  and 

Transverse  of  Ulna  with  Over-riding  of  Fragments. 

Pieces  of  shrapnel  scattered  over  hand  and  wrist. 

Fig.  50.    Loss  of  Bone  in  the  2nd  and  3rd  Metacarpals  with  New  Joint 
Formation.     (X-Ray  Fig.  48.) 

Fig.  51.     Loss  of  Portion  of  2nd  and  3rd  Metacarpal. 


FRACTURES  AND  DISLOCATIONS         177 

above.  This  fracture  is  commonly  caused  by  the  back 
kick  of  an  automobile  engine. 

Fracture  of  Radiios  and  Ulna.  The  deformity  is  more 
marked  and  sharper  and  there  may  be  overriding.  Green- 
stick  fractures  show  less  angular  deformity  and  the  mo- 
bility at  the  point  of  the"  fracture,  seen  in  through  and 
through  breaks,  is  not  present.  All  injuries  to  children 
which  could  cause  this  type  of  fracture  should  be  X-rayed. 
Setting  of  transverse  fractures  is  usually  not  difficult 
except  where  there  is  overriding.  This  overriding  must 
be  corrected  by  traction  before  attempting  to  reduce  the 
angle  deformity.  In  trying  to  reduce  angular  deformity 
pressure  should  not  be  made  directly  on  it,  but  above. 
Care  must  be  taken  to  avoid  tearing  the  soft  parts.  Anes- 
thesia may  be  required  and  the  open  method  can  then 
be  pursued  if  necessary.  A  broad  single  splint  will  suffice 
in  greenstick.  Anterior  and  posterior  splints  of  curved 
wood  may  be  used  where  both  bones  are  broken.  Much 
injury  has  been  done  by  too  tight  bandaging.  The  rule 
should  be  to  use  one  broad  splint  where  possible. 

The  Wrist. — Colles'  Fractures.  Colles'  fracture  is  a 
fracture  of  the  radius  about  three-quarters  of  an  inch 
from  its  lower  end.  It  is  usually  associated  with  back- 
ward displacement  of  the  lower  fragment,  giving  rise  to 
the  typical  ''silver  fork"  deformity,  with  occasional  ro- 
tation of  the  lower  fragment  toward  the  ulna.  The  close 
approximation  of  important  tendons,  the  function  of 
which  is  interfered  with  in  displacement,  makes  accurate 
reduction  of  great  importance. 

Reduction.    A  new  and  excellent  procedure  has  been 


178  ORTHOPEDICS 

outlined  by  Sir  Robert  Jones.  It  is  as  follows :  The  sur- 
geon grasps  the  patient's  forearm  with  one  hand  so  that 
he  can  exert  pressure  against  the  projecting  end  of  the 
shaft;  with  his  other  hand  on  the  back  of  the  patient's 
wrist  he  presses  on  the  displaced  fragment.  A  slight  pull 
and  twist  under  pressure  reduces  the  deformity.* 

Another  method  of  reduction  is  to  grasp  with  the 
thumbs  above  and  the  first  fingers  below  the  two  frag- 
ments. Use  traction  on  the  lower  fragment  to  free  it.  It 
may  be  necessary  to  increase  the  deformity  at  first  to  un- 
lock impaction.  Pressure  with  the  thumbs,  especially  the 
one  on  the  lower  fragment  to  correct  its  rerotation,  will 
bring  the  bones  into  proper  apposition. 

Where  vicious  union  has  taken  place  the  use  of  the 
Thomas  wrench  or  open  operation  may  be  necessary. 

Sprains  of  the  wrist  and  associated  synovitis  are  treat- 
ed as  those  elsewhere.  Careful  X-ray  work  will  reveal 
the  fact  that  many  supposed  sprains  are  in  reality  frac- 
tures. 

Dislocations.  Dislocation  of  the  wrist  is  rare.  The 
deformity  and  tenderness  are  below  the  wrist  joint.  The 
tenderness  is  diffuse  and  the  relation  between  the  styloid 
process  of  the  radius  and  the  ulna  is  undisturbed.  These 
dislocations  are  put  up  in  overextension  and  the  usual 
treatment  applied. 

The  Hand. — Fractures.  Fractures  of  the  phalanges 
and  metacarpals  may  follow  direct  violence  and  are  com- 
mon in  bare-hand  fighting. 

•Jones,    Col.    Sir    Eobert,    "Injuries    to    Joints" — ^Frowde,    London. 
Page  110. 


Fig.  52.     Extension  Applied  to  Fracture  of  Both  Bones  of  the  Forearm. 

Fig.  53.    Bradford  Frame  with  Extension  .\pplied  to  Leg  for  Fracture  op 
Femur  with  Shortening. 


FRACTURES  AND  DISLOCATIONS         181 

Diagnosis  and  treatment  are  usually  easy.  Fixation 
of  the  clenched  hand  over  a  roller  bandage  with  adhesive 
is  a  convenient  means  of  splinting  the  metacarpals.  A 
straight  posterior  splint  or,  if  preferred,  an  anterior  one, 
the  splint  being  slightly  wider  than  the  finger,  may  be 
used  for  fixation  of  the  phalanges. 

The  metacarpo-phalangeal  joints  are  condyloid  and  al- 
low adduction,  abduction  and  circumduction,  in  addition 
to  flexion  and  extension.  There  are  two  lateral  and  one 
anterior  ligament,  the  extension  tendon  serving  this  pur- 
pose posteriorly.  There  is  great  variation  among  differ- 
ent individuals  in  the  normal  range  of  movement  possi- 
ble. The  thumb  and  index  finger  are  the  most  frequently 
injured.  These  joints  may  be  dislocated  in  any  direc- 
tion. 

Diagnosis  is  easily  apparent  by  the  displacement  of  the 
finger.  Occasionally  the  anterior  ligament  makes  re- 
duction difficult.  When  there  is  overriding,  increase  the 
deformity  until  the  distal  bone  can  be  started  over  the 
head  of  the  proximal.  Fixation  with  early  passive  move- 
ment is  indicated. 

Dislocation  of  the  carpal-metacarpal  joint  is  usually 
confined  to  the  first,  which  is  easily  diagnosed  and  re- 
duced. A  curved  splint  extended  over  the  base  of  the 
thumb  will  retain  the  corrected  position. 

Dislocations.  Dislocation  of  the  phalangeal  joints  is 
obvious ;  the  pain  and  displacement  usually  marked.  Ex- 
tension with  accurate  setting  and  the  fixation  is  all  that 
is  required.     These  injuries  are  common  in  athletics, 


182  ORTHOPEDICS 

often  following  awkward  catching  of  a  baseball  or  bas- 
ketball, and  tend  to  recur  easily. 

Separation  and  displacement  of  the  epiphysis  instead 
of  dislocation  at  the  joint  is  common,  and  perfect  re- 
alignment with  fixation  for  two  weeks  is  necessary. 


Chapter  Xn 
FRACTURES  AND  DISLOCATIONS  (Con't) 

THE  LOWEB  EXTREMITY 

Pelvis. — Types  of  Fracture.  The  following  varieties  of 
fracture  of  the  pelvis  may  be  seen :  1.  Fracture  through 
the  rami  of  the  ischium.  2.  Fracture  of  the  acetabulum. 
3.  Fracture  of  the  tuberosity  of  the  ischium.  4.  Frac- 
tures of  the  iliac  crest.  5.  Fracture  of  the  anterior  su- 
perior spines. 

Fractures  of  the  Rami.  These  fractures  result  from 
falls  or  blows  on  the  front  of  the  pelvis,  or  by  crushing 
from  the  side.  They  may  include  the  pubic  bone  or  be 
complicated  by  fractures  near  the  sacro-iliac  joint  or 
communicating  with  it.  Displacement  is  not  usually 
great,  though  it  may  be  at  first  followed  by  partial  re- 
turn to  position.  During  its  excursion  it  may  extensively 
injure  the  soft  parts,  which  must  be  carefully  examined 
for  injury  in  all  fractures  of  this  type. 

Symptoms  noted  are  hemorrhage,  pajn  and  local  ten- 
derness, aggravated  by  leg  movements,  but  are  limited 
to  the  affected  side.  Mobility  and  crepitus  are  occasion- 
ally present.  Displacement  is  uncommon,  but  if  present 
replacement  manually  is  not  difficult.  We  treat  by  sup- 
port by  a  sandbag,  strapping  or  a  snug,  heavy  bandage, 

183 


184  ORTHOPEDICS 

canvas  and  leather  supports  are  often  useful.    Good  re- 
covery of  function  is  the  rule. 

When  complicated  by  a  fracture  at  the  back  of  the 
pelvis,  so-called  double-vertical  fracture,  which  is  usually 
caused  by  tremendous  pressure,  the  treatment  is  more 
complicated.  The  fragment  is  usually  displaced  upward ; 
occasionally  the  front  of  one  side  of  the  pelvis  and  the 
back  of  the  other  is  broken,  usually  with  less  displace- 
ment. The  main  symptoms  are — asymmetry,  mobility, 
pain,  etc.   X-ray  diagnosis  is  essential. 

The  pain  is  felt  both  front  and  back  on  bilateral  pres- 
sure upon  the  crests  of  the  ilia.  Treat  by  reducing  the 
upward  displacement  by  Buck's  extension  apparatus, 
using  eighteen  to  twenty-four  pounds.  If  the  patient  sur- 
vives the  extensive  shock,  fair  return  of  function  may  be 
hoped  for. 

Fracture  of  the  Acetabulum.  This  fracture  is  often 
complicated  with  backward  dislocation  of  the  hip  joint 
and  may  cause  recurrence  of  the  subluxation  beside  add- 
ing to  the  difficulty  of  replacement. 

Fractures  extending  through  the  center  of  the  acetabu- 
lum are  caused  by  the  impact  of  the  femoral  head.  Un- 
less the  head  penetrates  the  acetabulum  symptoms  are 
not  marked  and  the  condition  is  seldom  diagnosed.  Mo- 
bility and  the  bony  landmarks  remain  about  the  same. 
When  complicated  with  penetration  there  is  often  ex- 
tensive injury  to  the  soft  parts  and  the  injury,  though 
rare,  is  usually  fatal.  Usually  the  great  trochanter  of 
the  femur  is  less  prominent;  the  fascia  lata  is  relaxed; 
occasionally  there  is  outward  rotation  of  the  hip;  hem- 


FRACTURES  AND  DISLOCATIONS  (con't)     185 

orrhage  is  apt  to  be  severe.  The  leg  should  be  abducted 
and  extended  and  a  block  for  counter  pressure  may  be 
placed  between  the  thighs  so  that  the  femoral  head  is 
wedged. 

Prognosis  is  unfavorable  for  functional  recovery. 

Fracture  of  the  Iliac  Crests.  This  occurs  from  blows 
or  falls  on  the  side.  There  is  little  impairment  of  func- 
tion. Displacement  is  usually  inward.  Swelling,  tender- 
ness, crepitus  and  internal  displacement  are  marked.  It 
is  possible  to  reduce  the  fragment  occasionally  in  thin 
subjects.  Immobilize  with  adhesive  plaster  or  bandage 
with  even,  very  light  pressure.  Tight  bandaging  will 
force  the  fragment  inward.  Early  union  takes  place,  but 
at  least  four  weeks  must  be  allowed  before  the  fragment 
can  be  safely  pulled  upon  by  its  attached  muscles. 

Fractures  of  the  Anterior  Superior  Spine.  This  is 
rare,  but  is  occasionally  caused  by  direct  muscular  action 
in  sprinting  or  jumping.  Every  ''pulled"  tendon  should 
be  carefully  examined.    Displacement  is  not  great. 

Flex  the  leg  slightly  and  immobilize. 

Dislocation  of  the  Symphysis  Pubis. — Diagnosis.  This 
condition,  which  is  most  frequently  post-obstetric,  is  char- 
acterized by  pain  on  pressure,  or  by  abduction  of  the 
thighs  and  usually  hemorrhage.  More  marked  separation 
is  very  rare  but  may  occur  as  a  result  of  falls  or  horse- 
back riding.  In  such  cases  the  symptoms  are  more  marked 
and  may  be  accompanied  by  laceration  of  the  soft  in- 
ternal parts,  by  fractures  or  by  dislocation  of  the  sacro- 
iliac joints.  One  should  immobilize  by  a  pelvic  girdle, 
by  traction  and  immobilization  in  case  of  vertical  dis- 


186  ORTHOPEDICS 

placement,  or  wiring  in  case  of  separation  without  too 
extensive  injury;  generally  there  results  a  good  restora- 
tion of  function. 

Dislocation  of  the  Hip  Joint.  Hip  dislocation  is  rare 
in  comparison  with  fractures  of  the  femur  and  does  not 
warrant  the  space  given  to  this  subject  in  the  average 
text-book.  It  is  commonest  in  the  adult  male.  The 
simplest  classification  is  into  anterior  and  posterior  types, 
according  to  the  position  of  the  femoral  head  in  rela- 
tion to  the  acetabulum  and  the  ligaments,  especially  the 
Y  ligament  of  Bigelow. 

T[he  anterior  dislocations  are  sometimes  divided  into 
pubic,  suprapubic,  perineal  and  obturator  types,  and  the 
posterior  into  ischial  and  dorsal. 

Posterior  Dislocations,  the  commonest  type,  is  usually 
caused  by  falls  or  blows  from  in  back.  Inward  rotation 
makes  possible  this  backward  slipping,  especially  when 
accompanied  by  adduction  and  partial  flexion.  The  pos- 
terior and  inferior  fibers  of  the  capsule  are  torn.  The 
following  muscle  tendons  and  sometimes  the  muscles 
themselves  are  frequently  torn:  the  obturator  externus 
and  intemus,  quadratus  and  pyriformis  and  sometimes 
the  gluteus  maximus.  The  other  muscles  are  less  often 
affected.  When  this  dislocation  occurs  the  leg  is  held 
flexed  and  adducted;  there  is  often  some  real  and  a 
large  amount  of  apparent  shortening.  The  leg  is  also 
inverted  and  the  patient  may  rest  on  the  sound  foot.  All 
these  symptoms  are  aggravated  when  the  head  is  dislo- 
cated posteriorly  and  inferiorly  and  the  higher  its  posi- 
tion, the  less  marked  they  are.    The  head  is  absent  from 


FRACTURES  AND  DISLOCATIONS  (conH)     187 

its  normal  position  and  is  felt  posteriorly  and  is  felt  to 
move  on  any  movement  of  the  femur.  The  trochanter  is 
above  Nelaton's  line  and  shortening  is  found  by  the  usual 
measurement  from  the  anterior  superior  spine  to  the 
internal  malleolus.  A  still  more  accurate  measurement 
is  by  means  of  Bryant's  triangle.  The  patient  supine,  a 
line  between  the  great  trochanter  and  the  anterior  su- 
perior spine,  and  a  perpendicular  line  from  the  anterior 
superior  spine  to  the  table  are  drawn.  The  short  side  of 
the  triangle  will  be  the  horizontal  line  between  the  per- 
pendicular and  the  great  trochanter,  and  it  is  this  line 
that  is  shortened. 

Treat  by  Bigelow's  method.  Patient  supine,  the  leg 
is  adducted,  flexed  and  internally  rotated  followed  by 
forward  traction  and  abduction.  This  should  be  done  as 
one  continuous  movement  if  possible. 

There  is  considerable  injury  to  soft  parts  by  Bige- 
low's  method  which,  however,  is  a  great  improvement 
over  the  older  and  more  forceful  maneuvers.  Less  injury 
is  apt  to  be  done  by  the  Allis  and  gravity  method. 

The  Allis  Method.  Patient  supine,  the  thigh  and  knee 
are  flexed  to  right  angles  depressing  the  head  with  counter 
pressure  downward  on  the  pelvis  by  strap,  assistant  or 
surgeon's  foot,  the  surgeon  exerts  traction  upward  as  if 
trying  to  lift  the  patient  by  the  lower  leg,  the  femur  per- 
pendicular. Gently  rotate  inward  and  outward  several 
times,  each  followed  by  upward  traction  if  necessary. 

Gravity  Method.  Patient  lies  prone,  pelvis  at  end  of 
table,  hip  and  knee  flexed  at  right  angles.  Support  the 
ankle  and  give  gentle  pressure  downward  just  behind  the 


188  ORTHOPEDICS 

knee.  It  may  take  a  little  time  before  the  muscles  relax 
and  the  bone  slips  into  place.  If  one  or  both  of  these 
methods  fail,  then  the  Bigelow  method  should  be  tried. 

Anterior  Dislocation.  This  occurs  most  often  in  blows 
or  falls  on  the  abducted  leg.  Here,  too,  the  head  es- 
capes low  down  and  then  travels  forward  through  the 
lower  and  anterior  fibers.  The  Y  ligament  is  not  usually 
injured;  the  ligamentum  teres  is  usually  torn;  the  mus- 
cles are  rarely  injured.  The  leg  is  extended,  abducted 
and  rotated  outward;  the  patient  can  bear  considerable 
weight  on  the  leg.  The  head  is  displaced  inward,  gen- 
erally below  the  center  of  Poupart's  ligament.  The  Y 
ligament  generally  lies  in  close  apposition  to  the  neck 
and  may  be  used  as  a  fulcrum  to  restore  the  head  to  place. 

Allis  Method.  The  patient  lies  supine,  the  surgeon 
grasps  just  behind  the  flexed  knee,  abducts  the  slightly 
flexed  thigh  sharply  and  exerts  traction.  An  assistant 
presses  against  the  head  while  the  thigh  is  adducted. 

Rotation  Method.  This  method  is  attended  by  dan- 
ger of  injury  to  the  soft  parts  and  the  sciatic  nerve  and 
should,  therefore,  be  very  gently  performed.  It  may 
be  performed  in  two  ways: 

1.  Inward  Rotation.  The  thigh  is  partially  flexed  and 
then,  with  downward  traction,  is  abducted,  adducted  and 
rotated  inward  so  that  the  head  slips  into  place  and  the 
thigh  may  be  lowered  to  full  extension. 

2.  Outward  Rotation.  The  thigh  is  partially  flexed  and 
adducted,  the  knee  lowered  and  adducted  and  the  thigh 
then  rotated  outward. 

Fractures  of  the  Upper  End  of  the  Femur.    These 


FRACTURES  AND  DISLOCATIONS  (con't)     191 

fractures  are  divided  roughly  into  intra-capsular  and 
extra-capsular  types.  Displacement  varies  slightly  by 
the  plane  of  the  fracture  and  the  direction  of  the  muscle 
pull.  As  a  general  rule  in  fractures  of  the  neck  there  is 
overriding  of  the  lower  fragment  upward  which  is  cor- 
rected by  extension  in  the  abducted  position  with  slight 
inward  rotation.  Fixation  of  the  pelvis  as  well  as  the 
leg  is  essential,  and  fixation  of  the  whole  trunk  desirable. 
This  can  be  done  by  means  of  a  posterior  body  frame- 
brace  by  the  Thomas  posterior  splint  or  by  extending  the 
plaster  cast  to  the  axilla.  The  question  of  the  amount  of 
impaction  is  more  important  to  determine  than  the  exact 
location  of  the  break.  As  a  rule  impaction  favors  union. 
Fractures  at  the  Epiphysis  of  the  Head.  Injury  at 
this  point  is  of  fairly  common  occurrence  among  school- 
boy athletes.  It  often  follows  slight  trauma,  or  repeated 
slight  trauma,  the  symptoms  of  which  at  the  time  are 
mainly  those  of  hip  joint  strain  or  sprain.  For  this  rea- 
son it  is  very  often  not  discovered  for  some  time.  All  the 
movements  of  the  limb  may  be  normal  except  for  some 
pain  and  spasm  upon  abduction  and  rotation.  Increas- 
ing lameness  after  another  similar  injury  may  lead  to 
an  X-ray,  when  the  trouble  is  discovered.  Again  the 
symptoms  may  resemble  a  beginning  hip  tuberculosis 
with  some  limitation  of  movement  in  all  directions,  and 
obvious  shortening,  the  great  trochanter  being  above 
Nelaton's  line.  The  symptoms  also  resemble  coxa  vara 
and  some  authors  call  this  condition  traumatic  coxa 
vera.  We  must  also  differentiate  this  condition  from 
Perth's  disease,  or  osteochondritis,  with  its  flattening  of 


192  ORTHOPEDICS 

the  head  and  shortening  and  thickening  of  the  neck. 
Especially  difficult  is  it  without  the  help  of  the  X-ray  to 
differentiate  this  condition  from  late  rickets. 

Treatment  consists  in  abduction  and  extension  under 
anesthesia  if  necessary  with  fixation  for  five  or  six  weeks. 

Intracapsular  Fractures.  Fractures  of  this  type 
through  the  neck  of  the  femur  occur  most  often  in  late  life 
as  a  result  of  falls.  Sudden  twists  of  the  leg  are  suffi- 
cient to  produce  it  when  the  bone  is  much  rarefied. 

Pain,  mobility,  crepitus,  and  shortening  to  some  extent 
are  present.  Treatment  should  be  by  the  posterior  ab- 
duction frame  or  Thomas  splint  in  extension,  abduc- 
tion, and  slight  inward  rotation,  the  correction  of  the 
deformity  being  verified  by  the  X-ray.  Fixation  may  be 
obtained  by  plaster,  in  which  case  the  cast  should  run 
from  the  chest  to  the  toes.  Special  care  to  prevent  a  col- 
lection of  fluid  in  the  posterior  lobe  of  the  lung  by  too 
long  recumbency,  or  the  development  of  pressure  sores 
must  be  guarded  against. 

Extracapsular  Fractures.  These  are  more  apt  to  oc- 
cur in  adult  life  by  severe  blows  or  falls  on  the  trochanter. 
There  is  likely  to  be  firm  impaction  with  little  loss  of 
function  and  I  have  known  of  one  heavy  woman  who 
walked  for  weeks  with  such  a  fracture. 

More  marked  shortening  occurs  than  in  the  previous 
type  unless  there  is  impaction-.  Slight  eversion  of  the 
leg,  apparent  broadening  of  the  trochanter,  crepitus  and 
pain  are  noted. 

The  treatment  is  the  same  as  for  the  intracapsular 


FRACTURES  AND  DISLOCATIONS  (con't)     193 

type  except  when  there  is  marked  impaction  with  de- 
formity.   Here  the  impaction  must  first  be  broken  up. 

Fractures  of  the  Shaft  of  the  Femur.  These  fractures 
are  apt  to  be  oblique  with  considerable  tearing  of  the  soft 
parts. 

Symptoms.  Great  swelling  and  disability,  pain,  de- 
formity, marked  mobility  at  the  seat  of  the  fracture,  ro- 
tation of  the  leg  at  this  point  and  crepitus  are  noted. 
Measurements  unless  accurate  are  useless.  A  simple 
rule  is  to  lay  the  patient  on  a  hard,  even  surface  with  a 
vertical  line  corresponding  exactly  to  the  sagittal  plane 
and  another  at  right  angles  directly  under  the  anterior 
superior  spines. 

For  transportation,  if  necessary,  a  pillow  or  roll  of 
blankets  should  be  placed  around  the  extended  leg  sup- 
ported by  side  and  rear  splints  of  wood.  When  all  the 
material  is  at  hand  for  setting,  the  patient  may  be 
anesthetized.  The  foot  should  be  included  in  the  perma- 
nent dressing  and  kept  at  right  angles.  Extension  should 
be  by  means  of  weights  with  the  leg  elevated  by  a  Brad- 
ford frame  or  bed  elevated  at  the  foot. 

The  Caliper  Extension.  The  caliper  or  ice  tong 
method  of  extension,  devised  by  Major  F.  A.  Berley, 
has  been  used  with  good  success  in  the  army.  A  small 
incision  just  large  enough  to  admit  the  point  of  the 
caliper  is  made  just  over  the  most  prominent  part  of 
the  condyles  and  they  are  driven  about  a  quarter  of  an 
inch  into  the  bone,  a  little  higher  on  the  inner  side.  Care 
must  be  taken  not  to  enter  the  knee  joint.  The  leg  is 
slung  by  a  Balkan  frame  with  ten  to  fifteen  pounds  weight 


194  ORTHOPEDICS 

exerting  traction  in  the  line  of  the  femur.  This  position 
facilitates  nursing  the  patient,  and  infection  incident  to 
the  use  of  the  tongs  has  now  been  reduced  to  two  or 
three  per  cent. 

Fractures  of  the  Lower  End  of  the  Femur.  Surgical 
Anatomy.  Most  of  the  lateral  surface  of  the  condyles  is 
subcutaneous.  The  popliteal  artery  lies  close  to  the  pos- 
terior surface  and  is  often  pressed  upon  by  one  of  the 
fragments.  The  nerve  and  vein  of  the  same  name  are  fur- 
ther from  the  bone  and  not  as  often  injured.  The  most 
common  fracture  is  transverse,  just  above  the  condyles, 
but  they  may  be  fractured  separately  or  a  T  shaped  frac- 
ture may  extend  to  the  joint.  The  epiphysis  may  be 
separated.  A  fragment  may  be  displaced  in  any  direc- 
tion but  the  pull  of  the  gastrocnemius  will  usually  dis- 
place the  fragment  backward.  When  the  epiphysis  is 
separated,  on  the  other  hand,  it  is  usually  displaced  for- 
ward. There  are  pain,  swelling,  unnatural  mobility;  tfie 
leg  may  be  helplessly  rotated  outward ;  crepitus  may  be 
present.  Soft  crepitus  denotes  epiphyseal  separation  but 
overriding  and  shortening  are  the  rule. 

Anesthesia  is  usually  necessary.  Early  reduction  is 
essential  because  of  the  danger  of  possible  injury  to  the 
popliteal  artery.  Since  there  is  great  danger  of  injury  to 
this  vessel  by  the  manipulations  incident  to  setting,  great 
care  must  be  used.  Never  press  in  the  popliteal  space. 
Besides  the  caliper  method  mentioned,  the  Cabot  pos- 
terior wire  splint,  the  Dupuy  adjustable  splint  or  the 
Hogden  splint  may  be  used.  The  first  two  are  arranged 
in  a  double  inclined  plane.    Operative  treatment  is  indi- 


FKACTURES  AND  DISLOCATIONS  (con't)     195 

cated  whenever  good  reduction  cannot  be  obtained.  The 
incision  should  be  along  the  inner  border  of  the  quadri- 
ceps extensor.  The  use  of  the  bone-hooks  or  forceps  may 
be  necessary.  In  fractures  involving  the  joints  two  in- 
cisions may  be  necessary.  Open  the  knee  joint  only  as  a 
last  resort  and  then  only  under  rigid  aseptic  precau- 
tions. The  Lane  plate  or  bone  pegs  may  be  used  when 
the  epiphysis  is  not  involved. 

After  Treatment.  Considerable  swelling  and  some 
arthritis  of  the  knee  joint  are  to  be  expected.  The  use  of 
ice  is  an  important  aid.  Between  the  second  and  fourth 
weeks  the  knee  should  be  gradually  extended,  massage 
and  passive  movements  begun;  after  which  an  ambula- 
tory splint  may  be  worn  for  two  weeks. 

Fractures  of  the  Patella.  It  must  be  remembered  that 
the  patella  is  really  the  sesamoid  bone  enveloped  by  the 
tendon  of  the  quadriceps  extensor,  and  is  attached  below 
to  the  tubercle  of  the  tibia  by  the  patellar  ligament.  Its 
under  surface  directly  connects  with  the  knee  joint. 
Fractures  are  usually  transverse,  caused  by  blows  on  the 
flexed  knee.  Muscular  action  alone  causes  a  great  many 
fractures.  Many  of  them,  especially  of  the  lower  half, 
are  comminuted. 

Symptoms.  Pain  with  difficulty  or  inability  to  extend 
the  leg  is  constantly  present.  Crepitus  is  present  if  the 
fragments  are  not  too  widely  separated.  The  swelling 
is  rapid  and  extensive;  there  is  usually  considerable 
hemorrhage,  especially  at  the  sides.  With  improved 
technique  the  operative  method  is  to  be  preferred.  Bony 
union  seldom  follows  conservative  treatment.    In  non- 


196  ORTHOPEDICS 

operative  treatment  the  leg  should  be  well  padded  and 
splinted  behind;  the  leg  and  thigh  fixed  firmly  and  a 
figure  of  eight  strapping  crossing  at  the  sides  pressing 
the  fragments  firmly  together  should  be  used. 

Operative  Treatment.  The  knee  may  be  opened  by 
semi-lunar  incision,  concave  above,  or  by  vertical  incision. 
The  fragments  should  be  wired,  preferably  by  mattress 
suture  after  any  blood  clot  in  the  joint  has  been  removed 
and  the  joint  washed  out  with  saline.  The  patellar  lig- 
ament should  be  inspected  for  tears  and  any  such  re- 
paired. In  comminuted  fractures  all  small  fragments 
should  be  removed.  In  a  recent  case  of  extreme  fragmen- 
tation following  a  kick  by  a  horse  more  than  half  of  the 
patella  was  removed  with  an  excellent  functional  result. 
J.  T.  Rugh  of  Philadelphia  has  demonstrated  in  a  num- 
ber of  cases  that  a  patient  can  get  along  perfectly  well 
with  the  bone  excised.  Passive  movements  and  massage 
are  indicated  after  the  fourth  week.  If  healing  is  delayed 
protection  for  several  months  is  indicated. 

Dislocations  of  the  Patella.  These  injuries  are  not 
very  common ;  the  internal  are  more  common  than  the  ex- 
ternal subluxations.  The  symptoms  of  intense  pain,  loss 
of  function,  and  the  easily  recognized  deformity,  are 
marked. 

Spontaneous  reduction  may  take  place.  The  knee 
should  be  completely  extended  with  the  thigh  flexed: 
Slight  pressure  is  usually  enough  to  cause  it  to  slip  back 
into  place.  When  the  patella  is  rotated,  palpation  of  the 
ligament  will  show  the  direction.  Old  unreduced  cases 
may  necessitate  operation. 


FRACTURES  AND  DISLOCATIONS  (con't)     197 

After  Treatment.  A  supporting  bandage,  and  ice-cap 
if  necessary,  are  used,  and  careful  use  of  the  knee  for 
some  time  should  be  insisted  upon. 

Dislocation  of  the  Knee.  This  is  a  rare  condition.  The 
most  common  type  is  forward  and  backward,  outward  and 
inward  in  order.  We  get  pain,  swelling,  loss  of  function 
and  considerable  shock. 

Treat  by  traction.  Buck's  extension  if  necessary.  Oper- 
ation may  be  necessary  in  complete  dislocation.  Immob- 
ilize for  three  months  with  a  posterior  splint  and  watch 
the  circulation  carefully.  Stimulation  and  opiates  are 
sometimes  required  by  the  patient's  general  condition. 
Immobilize  for  three  months,  using  baking  frequently. 

Fractures  amd  Dislocations  of  the  Semi-lunar  Carti- 
lages. These  cartilages  are  semi-lunar  in  shape,  thick- 
ened at  their  margin,  the  inner  edge  being  free  in  the 
joint.  The  internal  cartilage  is  closely  associated  with  the 
internal  lateral  ligament  and  they  are  both  affected  by  the 
same  type  of  strain.  Sudden  pain  in  the  knee  after  strain 
or  injury  and  partial  flexion  is  noted.  The  joint  locks  and 
extension  is  impossible.  After  manipulation  a  sudden 
snap  is  felt  in  the  joint  with  return  of  normal  function. 
Inflammatory  reaction  is  set  up  in  the  joint  tissues  and 
persists  for  a  varying  length  of  time.  Recurrence  with 
increasing  frequency  is  the  rule.  Occasionally  locking  is 
not  present.  The  internal  cartilage  is  the  most  often  in- 
jured.   The  pain  may  be  here  or  referred  to  the  patella. 

Place  the  patient  prone,  knee  flexed,  rotate  slowly  from 
side  to  side.  Flexing  the  knee  over  the  surgeon's  wrist  is 
a  means  of  separating  the  articular  surfaces  of  the  joint. 


198  ORTHOPEDICS 

Free,  painless  extension  is  the  sign  of  reduction  of  the 
deformity.  The  knee  should  then  be  protected  from  over- 
use or  strain  by  a  simple  hinge  brace.  In  recurrent  cases 
the  cartilage  should  be  excised. 

Rupture  of  the  Crucial  Ligaments.  This  follows  se- 
vere twists  of  the  knee.  Almost  immediately  there  are 
severe  pain  and  great  swelling  which  make  the  joint  inse- 
cure. The  function  of  the  anterior  ligament  is  to  prevent 
forward  displacement  of  the  tibia  and  it  is  tense  in  com- 
plete extension  of  the  leg.  The  posterior  ligament,  on 
the  other  hand,  holds  the  tibia  forward  and  is  placed  in 
tension  when  the  knee  is  completely  flexed.  Acting  to- 
gether, they  prevent  twisting  of  the  leg  inward.  Testing 
these  different  movements  will  show  the  extent  of  the  in- 
jury which  has  taken  place. 

Treat  by  fixation  in  extension;  a  posterior  splint  fol- 
lowed by  the  use  of  the  hinge  brace  is  recommended. 
Operative  interference  is  seldom  indicated.  The  spine  of 
the  tibia  is  sometimes  torn  off  in  association  with  rup- 
ture of  these  ligaments.  The  knee  should  be  put  up  in  full 
extension.    X-ray  diagnosis  is  essential. 

Fracture  of  the  Upper  End  of  the  Tibia  and  Fibula. 
Fractures  of  Tibial  Tuberosities.  We  find  disability, 
pain,  swelling  and  traumatic  arthritis  are  present ;  lateral 
stability  of  the  knee  is  often  lost.  The  deformity  is 
usually  recognized  since  it  is  subcutaneous.  Separation 
of  the  upper  epiphysis  of  the  tibia  is  rather  rare;  the 
fragment  may  be  displaced  in  any  direction  and  crepitus 
is  soft. 

Fracture  of  the  Upper  End  of  the  Fibula,    There  are 


FRACTURES  AND  DISLOCATIONS  (con't)     201 

pain  and  local  tenderness,  but  less  involvement  of  the 
knee  and  less  disability;  the  head  may  be  movable;  the 
perineal  nerve  may  be  injured.  Reduce,  immobilize,  and 
begin  passive  movement  and  massage  the  third  week.  In 
case  of  impaction  use  Buck's  extension.  Operative  treat- 
ment may  be  necessary.  Treatment  may  have  to  be  ap- 
plied to  the  knee  joint. 

Fractures  of  the  Shaft  of  the  Tibia  and  Fibula.  These 
fractures  are  rather  common  from  either  direct  or  indi- 
rect violence.  Fracture  of  either  bone  separately  is 
usually  the  result  of  a  direct  blow.  Compound  fractures 
are  common. 

Pain,  swelling  and  deformity,  abnormal  mobility,  and 
crepitus  are  common.  Abnormal  mobility  is  greater  when 
both  bones  are  broken.  There  may  be  little  loss  of  func- 
tion in  fractures  of  the  fibula  alone.  Hemorrhage  is  often 
severe.  The  greenstick  fractures  of  chOdren  sometimes 
present  few  symptoms  but  pain  and  bowing.  The  diagno- 
sis is  made  by  X-ray. 

For  transportation  the  leg  should  be  splinted  both  sides 
and  rear,  supported  below  the  foot  and  well  padded.  Ex- 
tension applied  to  the  foot  flexed  nearly  to  a  right  angle  is 
useful.  Posterior  wire  splints  or  plaster  splints  are  com- 
monly used.  Operative  treatment  should  be  instituted 
wherever  good  apposition  is  otherwise  impossible.  An 
ambulatory  splint  should  be  used  if  possible  at  the  end 
of  the  first  week.  Great  caution  is  necessary  when  begin- 
ning use  of  the  limb.  Weight  bearing  should  be  extremely 
gradual  and  the  condition  of  the  callus  watched  by  the 


202  ORTHOPEDICS 

X-ray.  Heat,  massage,  and  passive  movements  of  the 
ankle  and  knee  should  be  used  early. 

Fractures  of  the  Lower  End  of  the  Tibia  and  Fibula. 
Pott's  Fracture,  This  is  a  combination  of  fracture  and 
dislocation. 

Surgical  Anatomy.  The  ankle  joint  is  formed  by  the 
fibula  externally,  the  tibia  above  and  internally  and  the 
astragalus  below.  The  two  leg  bones  are  bound  by  the 
strong  tibio-fibular  ligaments.  The  lateral  Ugaments  are 
also  very  strong  and  are  more  apt  to  be  pulled  away  than 
torn  through.  The  external  malleolus  is  longer  and  lower 
than  the  internal.  The  weight-bearing  surface  of  the 
heel  is  slightly  outside  in  the  longitudinal  plane  of  the 
tibia,  hence,  landing  squarely  on  the  feet  with  great  force 
tends  to  lateral  and  upward  displacement  of  the  foot. 
This  force  is  applied  directly  against  the  lower  end  of  the 
fibula  and  on  the  internal  lateral  ligament.  Either  this 
ligament  is  ruptured  or  the  tip  of  the  malleolus  is  torn  off. 

There  are  absolute  loss  of  function,  pain,  swelling  and 
characteristic  eversion  of  the  foot;  the  greater  promi- 
nence of  the  internal  malleolus ;  crepitus  is  usually  lack- 
ing and  the  heel  may  appear  prominent.  Marked  swell- 
ing may  mask  the  symptoms;  delayed  hemorrhage  is 
often  seen. 

Inversion  and  upward  replacement  of  the  foot  is  nec- 
essary. The  padded  internal  splint  of  Dupuytren  should 
be  used  early.  The  padding  just  above  the  fracture  is 
used  as  a  fulcrum  to  invert  the  foot.  The  Cabot  wire 
splint  may  be  used  throughout.  Stimson*s  plaster  splint 
is  best  after  the  first  week.    It  consists  of  a  posterior  seg- 


FKACTURES  AND  DISLOCATIONS  (con't)    203 

ment  from  the  knee  to  the  toes  and  an  external  one  which 
is  continued  beneath  the  foot  and  over  its  dorsum  to  the 
external  malleolus.  The  foot  must  be  placed  at  a  right 
angle.  The  splint  should  remain  on  five  or  six  weeks, 
massage  begun  in  the  second  week.  Weight  bearing 
should  be  gradual  and  guarded. 

Fracture  of  Both  Bones  Above  the  Ankle.  The  symp- 
toms are  pain,  swelling,  loss  of  function,  crepitus,  preter- 
natural mobility.  The  deformity  is  usually  marked  and 
easily  recognized. 

Treatment  is  the  same  as  for  fractures  of  the  shaft. 

Dislocation  of  the  Ankle.  These  are  usually  forward 
or  backward.  Lateral  dislocations  are  generally  associ- 
ated with  fracture. 

Posterior  Dislocations.  Prominence  of  the  tibia  and 
the  obvious  deformity  are  seen. 

Place  the  patient  supine,  fix  the  ankle  with  traction 
downward,  grasp  behind  the  heel,  pull  backward,  down- 
ward, forward. 

Forward  Dislocations.  This  is  usually  associated  with 
fracture,  and  if  so,  operative  treatment  may  be  necessary. 

Fractures  of  the  Tarsus.  These  should  be  diagnosed 
by  the  X-ray,  replaced  as  well  as  possible  and  immobilized 
with  plaster. 

Fractures  of  the  Metatarsus.  The  symptoms  vary 
greatly  with  the  severity  of  the  injury.  Crushed  wounds 
often  cause  multiple  fractures  with  extensive  damage  to 
the  soft  parts.  Pain,  swelling,  crepitus,  and  tenderness 
are  the  usual  symptoms.  Pressure  beneath  the  toes  on 
the  head  of  the  metatarsal  bones  is  one  method  of  elicit- 


204  OBTHOPEDICS 

ing  pain.    Eeduce  the  deformity  by  pressure  pad  and 
immobilize  in  a  cast. 

Fractures  and  Dislocations  of  the  Phalanges.  The 
symptoms  are  similar  to  those  described  for  the  fingers. 
The  deformity  should  be  reduced  and  the  foot  encased  in 
plaster.  Where  the  injury  has  been  done  to  the  great  toe, 
the  patient  should  not  be  allowed  to  walk  until  bony  union 
has  taken  place  or  inflammatory  reaction  has  subsided. 
In  the  other  phalanges  use  may  be  allowed  much  earlier. 


Chapteb  XIII 

FOOT  STRAIN 

The  Main  Arch.  Classification.  Three  degrees  of  this 
condition  have  been  described: 

1.  The  weak  foot.  This  is  a  condition  in  which  the 
patient  complains  of  discomfort  or  pain  in  the  arch  when 
overfatigued  or  following  prolonged  use  of  the  foot,  es- 
pecially during  hot  weather.  The  arch  is  little,  if  any, 
lowered. 

2.  The  strained  foot.  Here  the  arch  is  coming  down. 
The  pain  is  very  severe  and  may  be  referred  to  the  back 
of  the  leg,  front  of  the  thigh,  or  even  the  back.  The  sca- 
phoid is  usually  prominent.  This  condition  must  be  vis- 
ualized as  the  breaking  stage. 

3.  Absolute  flat  foot.  Here  the  damage  has  been  done. 
The  arch  is  flat  and  the  inner  border  of  the  foot  bulges 
considerably.  There  is  no  pain  and,  indeed,  sometimes 
never  has  been,  if  the  condition  is  gradual  enough  in  its 
onset.  The  patient  often  consults  the  orthopedist  because 
some  person  has  told  him  he  is  flat  footed,  or  because  he 
has  been  rejected  from  the  service.  The  author  has  been 
consulted  by  many  young  men,  from  naval  recruiting  sta- 
tions, who  were  utterly  unaware  of  the  existence  of  this 
condition  or  their  probable  rejection  from  the  service  on. 

account  of  it. 

205 


206  ORTHOPEDICS 

Causes.  Before  any  intelligent  conception  of  the  rea- 
sons underlying  the  great  prevalence  of  this  condition  can 
be  gained,  it  is  necessary  to  consider  the  way  in  which 
savage,  or  natural,  man  used  his  feet,  and  the  extensive 
changes  that  civilization  has  brought  about.  The  normal 
movement  of  the  bare  or  moccasined  foot  in  walking  is  a 
grasping  one,  which  constantly  exercises  the  three  layers 
of  muscle  whose  normal  tone,  with  the  long  and  short 
plantar  ligaments,  helps  to  retain  the  form  of  the  arch. 
The  foot  is  pointed  straight  forward  or  slightly  toeing  in ; 
the  heel,  outer  border,  ball  of  the  foot  and  toes  carry  the 
weight. 

"We  no  longer  usually  walk  upon  sand  or  springy  turf, 
but  a  rapidly  increasing  part  of  our  population  is  con- 
demned to  solid  pavements  and  hardwood  floors,  and  such 
conditions  cause  strain.  It  being  considered  the  proper 
thing  to  toe  out,  it  is  insisted  upon  that  the  child  fall  in 
line  with  this  convention.  In  such  a  foot  position,  since  the 
momentum  of  the  body  is  going  straight  forward,  if  the 
weight  hits  the  heel  on  the  outer  side  with  the  foot 
everted,  it  must  necessarily  be  transmitted  across  the  foot 
directly  onto  the  arch,  instead  of  along  the  outer  border 
of  the  foot,  and  straight  forward. 

We  further  impede  normal  use  of  the  arch  muscles  by 
placing  a  rigid  leather  sole  on  the  shoe.  In  women's  shoes 
several  points  in  consideration  of  the  heel  are  important. 
The  very  high  heel,  by  causing  long  held  contraction  of 
the  calf  muscle,  may  lead  to  its  structural  shortening. 
This  height  induces  an  artificially  high  arch,  which  is 
withal  a  weak  one.    It  makes  such  a  steep  incline  in  the 


^K^R^^^^^^^^^^^^^^^^^^^^V 

'Hi  ^HK^ 

Fig.  59.    Exercise  II.    Walking  Forward  on  Outer  Edge. 
Fig.  60.    Exercise  III.    Rising  on  Toes,  Toeing  in. 
Fig.  61.    Exercise  IV.    Walking  Forward  on  Outer  Edge,  Toeing  in. 
Fig.  62.    Exercise  V.    Ground  Gripper  Walk. 


FOOT  STRAIN  209 

shank  that  efficient  weight  bearing  there  is  impossible  and 
the  weight  is  unduly  thrust  forward  onto  the  ball  of  the 
foot.  Constant  variations  in  the  height  of  the  heel  are  in 
themselves  a  danger  because  they  do  not  allow  time  for 
readjustment  of  the  muscles  and  ligaments  to  varied 
planes  of  weight  bearing.  Moreover,  these  heels  are 
usually  extremely  small  in  base,  which  necessitates  a  stilt- 
like balancing  by  the  muscles  of  the  leg.  This  is  a  most 
severe  type  of  exertion  and,  occurring  in  that  part  of  the 
body  where  the  removal  of  waste  products  is  most  slug- 
gish, it  is  no  wonder  that  fatigue  and  strain  almost  inev- 
itably ensue.  Still  further,  the  shortness  of  such  a  heel 
fails  to  give  support  far  enough  forward  under  the  os 
calcis  and  so  brings  increased  strain  on  the  arch.  The 
constricted  fore  part  of  the  shoe,  absolutely  eliminating 
the  normal  spread  and  movement  of  the  toes,  adds  its 
quota  of  injury.  Occupations  requiring  long  standing  or 
the  enforced  immobility  of  the  muscles  of  the  foot  are  a 
far  more  frequent  cause  of  flat  foot  than  walking.  Cer- 
tain constitutional  conditions  predispose  to  arch  trouble, 
especially  the  general  lack  of  muscular  tone  following 
acute  or  chronic  illness,  too  rapid  growth,  or  any  other 
condition  which  lowers  bodily  tone. 

Diagnosis.  Heretofore  great  emphasis  has  been  placed 
upon  the  arch  impression,  which,  when  normal,  is  sup- 
posed to  be  broad  in  the  heel  and  ball  of  the  foot  and  to 
show  only  the  outer  border  between  them.  A  low  or 
fallen  arch  is  indicated  by  the  breadth  of  the  central  part 
of  this  impression,  with  sometimes  a  total  obliteration  of 
the  curved  indentation  of  the  arch  in  the  normal  impres- 


210  OETHOPEDICS 

son.  Impressions  are  commonly  taken  by  means  of  water, 
powder,  lamp  black,  ferric  chloride  solution,  or  other  sub- 
stance applied  to  the  soles,  the  patient  standing  with  feet 
parallel  and  about  six  inches  apart,  his  weight  evenly  dis- 
tributed on  both  feet.  The  ferric  chloride  or  lamp  blacked 
paper  shellacked  may  serve  for  permanent  record.  An 
ingenious  device  is  the  small  plate  glass  stand  with  slant- 
ing mirror  beneath,  showing  the  pressure  imprint  of  the 
arch  to  the  surgeon  standing  in  front.  I  take  it  that  these 
impressions  are  of  little  intrinsic  value  except  when  kept 
in  series  as  a  record  of  the  success  of  the  treatment  given. 
The  most  painful  arches  I  have  ever  seen  have  been  nat- 
urally high  ones  that  were  beginning  to  break.  On  the 
other  hand,  the  exanodnations  of  several  hundred  normal 
students  of  physical  education  have  shown,  in  a  great 
majority  of  cases,  the  low  strong  arch  with  no  untoward 
symptoms.  This  fact  confirms  the  conclusions  of  Major 
John  Ridlon  of  Chicago,  embodied  in  his  advice  to  sur- 
geons examining  for  the  service,  that  the  low  arch,  show- 
ing good  strength  of  the  intrinsic  muscles  of  the  foot  and 
without  painful  symptoms,  was  much  more  apt  to  stand 
up  under  forced  marching  than  the  very  high  arch.  The 
pain,  with  its  frequent  reference  to  more  or  less  remote 
parts  of  the  body,  is  important.  Abduction  of  the  fore 
part  of  the  foot  must  be  looked  for  in  all  types.  A  ridge 
of  callus  along  the  outer  edge  of  the  foot  is  a  sure  sign  of 
faulty  weight  bearing. 

No  treatment  should  be  instituted  without  inverting  the 
foot  and  passively  flexing  it  to  determine  the  angle  of 
dorsal  flexion,  which  should  be  ten  to  fifteen  degrees  less 


FOOT  STRAIN  211 

than  a  right  angle.  A  flexion  limited  to  a  right  angle  or 
more  shows  the  mnscle-bound  foot  described  by  Hibbs. 
l^roper  treatment  for  that  condition,  consisting  of  the 
fi' stretching  of  the  calf  muscle,  if  possible,  if  not,  by  oper- 
ative lengthening  of  the  Achilles  tendon,  must  be  insti- 
tuted before  attempting  to  treat  the  arch.  These  pa- 
tients receive  a  strain  or  stretching  of  the  calf  muscle  just 
as  the  heel  leaves  the  ground  in  the  step,  and,  in  order  to 
decrease  the  amount  of  foot  flexion  necessary,  they  turn 
the  foot  out  more  and  more.  This,  as  before  shown,  trans- 
mits the  weight  more  directly  onto  the  arch  and  aggra- 
vates the  strain  upon  it.  They  are  given  temporary  re- 
lief by  certain  plates,  but,  more  often,  by  a  higher  heel, 
until  the  calf  muscle  takes  up  the  new  slack,  when  the 
vicious  cycle  is  repeated.  In  numerous  clinics  I  have  seen 
patients  arrive  with  a  bagful  of  arches  of  various  de- 
scriptions, when  this  condition,  the  root  of  their  trouble, 
has  been  overlooked. 

Treatment.  Individual  cause  must  first  be  sought  and 
if  possible  eliminated.  The  patient  should  walk  with  the 
foot  straight  forward.  He  should  wear  a  heel  of  moder- 
ate height,  broad  and  long,  especially  on  the  inner  side. 
A  wide,  sensible  heel  and  a  flexible  shank  is  often  of  ad- 
vantage. Beginning  cases,  as  of  type  1,  may  often  be 
cured  by  two  or  three  strappings  and  a  program  of  exer- 
cises. The  other  two  types  need  all  the  resources  at  our 
command. 

Strapping.  Strapping  is  usually  done  in  one  of  two 
ways :  1.  The  partial  figure  of  8.  This  is  a  long  doubled 
strapping  starting  at  the  inner  border  of  the  tibia,  cross- 


212  ORTHOPEDICS 

ing  the  front  of  the  ankle  and  the  external  malleolus,  go- 
ing under  the  heel  at  the  anterior  border  of  the  os  calcis 
to  the  internal  malleolus,  crossing  in  front  of  the  ankle 
and  attached  to  the  outer  side  of  the  leg.  This  strapping 
is  intended  to  lift  up  the  front  part  of  the  heel  and  makes 
no  attempt  at  holding  the  foot  in  inversion.  It  takes  little 
plaster,  is  quickly  and  easily  applied  and  is  a  good  type 
for  dispensary  work. 

2.  The  basket  strapping.  This  consists  of  two  sets  of 
six  straps  each,  the  shorter  set  in  length  from  the  base  of 
the  toes  to  about  an  inch  over  the  heel,  the  other  set  six 
inches  longer.  With  the  foot  flexed  to  a  right  angle  and 
inverted  the  first  short  strap  is  placed  from  the  base  of 
the  small  toe  to  the  back  of  the  outside  of  the  heel.  The 
second  and  long  strap  is  started  just  over  the  dorsum  of 
the  foot  at  the  base  of  the  little  toe,  is  carried  diagonally 
under  the  ball  of  the  foot,  back  to  the  anterior  part  of  the 
arch,  up  across  the  front  of  the  ankle,  to  the  outer  side  of 
the  leg.  The  third  is  placed  parallel  to  the  first,  overlap- 
ping it  one-half  in  the  direction  of  the  arch.  The  fourth 
is  parallel  to  the  second  and  slightly  posterior  to  it,  so 
that  it  overlaps  it  one-half.  The  rest  are  placed  in  alter- 
nation, until  the  arch  is  covered  and  supported  in  its  cen- 
ter by  four  thicknesses,  the  result  of  the  interweaving  of 
the  two  groups.  This  strapping  holds  the  foot  in  slight 
inversion,  supports  the  arch  through  its  entire  length, 
and  has  been  most  satisfactory  in  practice.  Such  a  strap- 
ping should  last  from  four  to  seven  days  and  will  relieve 
symptoms  while  a  plate  is  being  made. 

Arch  Plates.    There  are  two  principles  involved  in  the 


FOOT  STRAIN  215 

prescribing  of  arch  supports.  One  is  thoroughly  to  sup- 
port the  arch  and  relieve  the  symptoms  consequent  to 
strain,  the  other  partially  to  support  and  assist  the  arch 
muscles  in  regaining  their  tone.  The  first  principle  is 
typified  by  the  Whitman  plate,  which  is  made  from  a  cast 
of  the  foot  and  so  gives  perfect  support.  It  consists  of 
an  outer  flange,  preventing  displacement  of  the  support, 
and  a  high  inner  flange,  which  supports  the  scaphoid  and 
prevents  the  rolling  in  of  the  ankle.  I  believe  this  to  be 
the  best  plate  for  patients  beyond  middle  life,  those  dis- 
tinctly over  weight,  or  those  whose  feet  are  rigid.  A  sec- 
ond plate,  on  the  principle  of  a  sling  or  hammock  for  the 
arch,  improved  on  greatly  by  E.  H.  Arnold  of  New 
Haven,  gives  partial  support  to  the  arch  by  means  of  two 
ribbons  placed  under  the  arch,  one  passing  over  the  dor- 
sum of  the  foot,  the  other  under  the  heel,  buckling  in  front 
of  the  internal  malleolus.  This  plate  allows  considerable 
movement  in  the  foot  muscles  without  abduction  of  the 
forefoot,  and  in  young  and  strong  patients,  where  the 
ability  to  regain  normal  muscular  power  remains,  has 
given  extremely  satisfactory  results.  The  leaving  off  of 
this  support,  after  it  has  performed  its  function,  does  not 
usually  lead  to  a  renewed  relaxation  of  the  arch  muscles. 
The  ordinary  stock  plate  neither  fits  the  individual  pa- 
tient, nor  assists  the  return  of  muscular  function,  nor 
gives  adequate  support  and,  therefore,  is  usually  a  fail- 
ure. Moreover,  nearly  every  type  of  arch  plate  on  the 
market  compels  the  abduction  of  the  forefoot. 

Massage.    Frictions  of  the  arch  can  be  done  easily  by 
the  patient  himself  and  should  be  followed  by  stroking. 


216  ORTHOPEDICS 

This  is  a  valuable  means  of  improving  the  circulation  and 
relieving  fatigue. 

Exercises.  Of  the  many  kinds  of  exercise  that  have 
been  tried  the  following  are  typical  examples  and,  when 
coupled  with  the  above  outlined  forms  of  treatment,  will 
greatly  hasten  a  return  to  normal: 

1.  Stand  with  the  feet  parallel  and  roll  out. 

2.  Stand  with  the  feet  parallel  and  walk  forward  on 

the  outer  edge,  keeping  the  toes  flexed  as  far  as 
possible. 

3.  Toe  in  and  rise  on  toes. 

4.  Walk  forward  on  the  outer  edge,  toeing  in. 

5.  Ground  gripper  walk.    Step  forward,  flex  the  toes 

.  to  the  greatest  possible  extent,  and  relax.    Re- 
peat step  forward  with  other  foot. 

6.  Pick  up  marbles  with  the  toes. 

Anterior  arch.  The  anterior  arch  extends  transversely 
across  the  fore  part  of  the  foot  and  is  formed  by  the  an- 
terior ends  of  the  metatarsal  bones  at  right  angles  to  the 
main  arch.  It  is  supported  by  the  transverse  metatarsal 
ligament  and  the  transversus  pedis  muscle.  Strictly 
speaking,  it  is  not  a  real  arch  since  it  always  disappears 
under  weight  bearing. 

Cause.  Obliteration  of  the  anterior  arch,  often  called 
**  anterior  metatarsalgia,''  is  very  much  more  frequently 
diagnosed  now  than  a  few  years  ago.  Its  more  common 
occurrence  is,  in  large  measure,  due  to  the  increased 
vogue  of  the  thin-soled,  high-heeled  shoe  and  pump,  and, 
to  some  extent,  to  the  increased  amount  of  hard  pave- 


FOOT  STRAIN  217 

ments.  With  the  falling  of  the  main  arch  there  is  an  in- 
ternal rotation  at  the  metatarso-phalangeal  joint  that  pro- 
duces marked  ligamental  strain. 

Diagnosis.  As  before  stated,  the  high  heel  necessitates 
the  crowding  forward  of  an  undue  amount  of  weight  upon 
the  ball  of  the  foot.  The  thin  sole  very  frequently  curls, 
in  such  a  way  as  to  form  a  hollow  inside  the  shoe.  Into 
this  the  anterior  arch  is  apt  to  fall,  by  first  spreading  the 
but  slightly  resistant  upper  of  the  shoe,  and  then  drop- 
ping and  assuming  the  shape  of  the  sole.  Nature  may  at- 
tempt to  build  it  up  by  forming,  underneath  the  foot,  a 
pad  of  callus,  which  is  often  the  first  sign  of  impending 
trouble  at  this  point.  The  pain  is  sharply  localized  near 
the  head  of  the  second  metatarsal  bone  and  is  extremely 
acute  in  character.  An  interesting  case  in  point  is  that 
of  a  young  woman  of  nineteen,  who  came  to  the  dispen- 
sary with  all  the  classic  symptoms  of  this  condition.  Her 
case  had  been  diagnosed  and  routine  treatment  had  been 
applied  on  several  occasions  without  result.  X-ray 
showed  tuberculosis  of  the  distal  end  of  the  second  meta- 
tarsal bone  of  each  foot,  an  extremely  rare  bilateral  man- 
ifestation of  this  disease,  which  was  then  treated  by  the 
appropriate  means  with  good  result.  I  cite  this  case  as 
an  example  of  the  fact  that,  where  the  recognized  treat- 
ment of  any  apparent  orthopedic  condition  has  repeat- 
edly failed,  we  should  exhaust  all  means  at  our  command 
before  giving  the  case  up  or  continuing  the  ineffectual 
treatment.  It  must  not  be  forgotten  that  one  may  be 
dealing  with  a  referred  pain  from  longitudinal  arch 
strain. 


218  ORTHOPEDICS 

Treatment.  The  treatment  of  this  condition  is,  first,  to 
eliminate  the  cause,  for  instance,  by  a  thick-soled,  sen- 
sible shoe ;  by  the  removal  of  the  of ttimes  painful  callus 
by  chromic  acid  or  other  means ;  by  the  use  of  strapping, 
or  a  support,  as  well  as  passively  attempting  to  remold 
the  arch ;  by  the  use  of  exercises,  one  being  a  picking  up 
of  marbles  or  other  small  objects  with  the  toes.  Other 
exercises,  such  as  flexion  and  extension  and  the  longi- 
tudinal arch  exercises,  help  greatly.  Sometimes  a  circu- 
lar adhesive  strapping  running  several  times  around  the 
fore  part  of  the  foot,  the  arch  being  held  in  a  corrected 
position,  will  suflSce.  A  very  excellent  pad  can  be  made 
from  a  circular  piece  of  chamois,  a  little  larger  than  a 
silver  dollar,  surrounding  a  piece  of  cotton  and  securely 
sewed,  so  as  to  be  about  the  size  of  a  half  dollar  and  two 
or  three  times  as  thick.  If  this  is  not  at  hand,  a  simple 
pad  of  cotton  will  often  bring  immediate  relief  when  held 
in  place  by  the  above  mentioned  circular  adhesive  strap- 
ping. A  laced  "collar"  with  pocket  for  pad  is  usefuL 

AKMY   TREATMENT  OP  FOOT  AILMENTS 

Strained  Foot.  The  methods  of  classifying  and  treat- 
ing acute  and  chronic  foot  strain  in  the  Army  is  so  dif- 
ferent from  that  heretofore  used  in  private  practice,  that 
to  avoid  confusion  it  may  be  dealt  with  separately  in  this 
section. 

Literature.  The  latest  material  will  be  found  in  the 
"War  Department  Manual,  "Minor  Foot  Ailments"  and 
"Medical  Manual  No.  4"  (Military  Orthopaedic  Surgery), 
Colonel  Sir  Robert  Jones '  work  on  * '  Military  Orthopaed- 


FOOT  STRAIN  219 

ics,"  Colonel  Munson's  book,  **The  Soldier's  Foot  and 
the  Military  Shoe,"  and  the  printed  lectures  of  Captain 
W.  J.  Merrill  of  Philadelphia,  delivered  at  the  Camp 
Greenleaf  School. 

Viewpoint  of  Military  Orthopedics,  It  is  now  the  con- 
sensus of  opinion  that  we  are  dealing  with  soldiers  dis- 
abled or  potentially  disabled  (amounting  at  times  to  ten 
per  cent  of  the  troops)  by  (1)  weak  muscles,  (2)  acute 
or  chronic  foot  strain,  (3)  arthritis  or  ostitis,  secondary 
to  focal  or  systematic  infection. 

Classification.  Following  to  some  extent  the  classifi- 
cation of  Jones,  the  soldiers '  feet  are  divided  into  the  fol- 
lowing types:  (1)  Weak  foot,  (2)  Flaccid  flat  foot,  (3) 
Rigid  foot:  (a)  Muscle  bound,  (b)  Contracted,  (c)  Rigid, 
(d)  Spastic,  (e)  Claw  (first,  second  and  third  degrees). 

Anatomy.  The  weight  bearing  is  done  normally  when 
the  heel  is  raised,  by  the  inner  three  segments  of  the  meta- 
tarsals, cuneiforms,  scaphoid  and  astragalus.  The  os  cal- 
cis,  cuboid  and  outer  two  metatarsals  add  lateral  stability. 
Movement  involving  flexion  and  extension  of  the  foot — 
or,  as  it  is  called  in  the  Army,  plantar  flexion  and  dorsal 
flexion — takes  place  on  the  trochlear  surface  of  the  as- 
tragalus. Lateral  movement  occurs  in  the  subastraga- 
loid  joint  and  between  the  head  of  that  bone  and  the 
scaphoid.  (This  point  is  important  to  bear  in  mind  when 
judging  the  claims  for  merit  of  several  styles  of  shoes 
which  are  supposed  properly  to  adduct  the  foot.  In  the 
types  I  have  in  mind  the  foot  is  not  grasped  far  enough 
back  by  the  shoe,  and  the  toes  are  merely  crowded  out 
of  alignment.)     It  should  never  be  forgotten  that  liga- 


220  ORTHOPEDICS 

ments  are  non-elastic  and  non-sensitive,  and  that  the 
pain  of  strained  foot  occurs  very  often  where  the  liga- 
ments attach  to  or  pierce  the  periosteum,  which  struc- 
ture is  extremely  sensitive. 

Methods  of  Examination.  "The  examination  of  the 
soldier's  feet  begins  at  his  head."  This  axiom  indicates 
the  close  association  and  importance  of  bodily  posture  to 
foot  strain.  A  clear  picture  of  the  normal  posture  and 
normal  foot  must  constantly  be  kept  in  mind.  (Place  pa- 
tient's feet  parallel  and  six  inches  apart.)  Determine  the 
lines  of  weight  bearing.  They  should  pass  anteriorly 
through  the  center  of  the  patella,  the  crest  of  the  tibia 
and  the  middle  of  the  second  toe.  In  the  rear  from  the 
center  of  the  popliteal  space  to  just  outside  the  center  of 
the  heel.  Examine  carefully  for  scars,  discolorations, 
swellings,  sweating.  Note  the  condition  of  the  toes — 
corns,  callosities,  hallux  valgus,  etc.  Manipulate  thor- 
oughly to  bring  out  any  restriction  of  normal  motion  or 
roughening  of  joint  surfaces.  The  following  exercises 
will  be  of  service  in  the  examination:  1.  Dorsal  flexion 
(overextension)  of  the  toes,  kept  straight.  2.  Eise  on 
heels,  foot  dosi-flexed.  3.  Rise  on  toes,  avert  ankles.  4. 
Supinate  foot  (bear  weight  on  outer  edge)  and  flex  toes. 

Diagnosis  and  Treatment.  1.  Weak  Foot.  In  this 
type  we  find  slight  pronation.  This  foot  cannot  perform 
the  common  exercise  movements  normally.  The  muscles 
are  untrained  and  hence  liable  to  break  down  under  un- 
usual exertion.  Any  foot  which  shows  the  weakness  out 
of  proportion  to  the  obvious  deformity  should  be  placed 
in  this  group.    These  feet  should  be  treated  by  proper 


FOOT  STRAIN  221 

shoes  with  wedge  or  Thomas  heel  if  desired,  exercises, 
passive  movements,  massage  and  contrast  baths.  This 
type  must  be  noted  in  the  history. 

2.  Flaccid  Flat  Foot.  There  is  much  obvious  deform- 
ity in  this  type — marked  pronation,  prominent  scaphoid, 
abducted  forefoot,  and  often  flattened  transverse  arch. 
The  important  point  is,  however,  that  the  foot  can  go 
through  the  standard  exercises  in  a  nearly  normal  man- 
ner. The  treatment  is  similar  to  that  just  given  for  weak 
foot. 

3.  Advanced  Type  with  Joint  and  Muscle  Complica- 
tions. 

(a)  Muscle  Bound.  These  conditions  are  brought 
about  by  over-use  per  se,  at  times  but  a  careful  search  will 
generally  reveal  some  constitutional  disorder  at  the  root 
of  it.  Indeed,  Captain  Merrill  states  that  in  his  opinion 
over  ninety-five  per  cent  of  these  cases  are  due  to  infec- 
tion somewhere  in  the  body.  The  teeth,  tonsils,  gastro- 
intestinal tract,  urethra  or  prostate  are  the  points  of  pre- 
dilection. 

We  must  then  seek  the  focus  of  infection  and  if  still 
active,  eliminate  it.  This  done,  a  short  rest  from  strain 
will  allow  of  nearly  normal  movements  being  executed. 
The  treatment  by  massage,  exercises,  etc.,  will  then  rap- 
idly restore  the  foot  to  full  usefulness. 

(b)  Contracted.  Here  there  is  actual  structural  short- 
ening added  to  muscle  spasm.  The  conditions  found  in 
the  muscle-bound  foot  are  present  in  aggravated  form. 
Try  to  locate  the  constitutional  predisposing  cause. 
Treat  as  above  outlined. 


222  ORTHOPEDICS 

(c)  Rigid.  An  infectious  process  has  been  at  work  on 
the  joints  of  the  tarsus  and  mid-tarsus.  Gonorrhea  is  a 
common  cause,  supplemented  by  foot  strain.  Here  pros- 
tatic massage  and  medication  should  be  added.  If  the 
palliative  measures  used  above  do  not  cause  a  return  of 
flexibility  the  patient  may  be  anesthetized,  the  foot  placed 
over  a  padded  Koenig  block  and  the  adhesions  broken  up. 
Pl&ce  in  a  cast,  the  foot  being  inverted,  flexed  to  90  de- 
grees and  supinated.  It  should  remain  in  the  cast  two  or 
three  weeks  and  then  the  regular  treatment  instituted  as 
for  the  other  types  heretofore  outlined. 

(d)  Spastic.  In  this  type  we  have  the  added  feature 
of  a  marked  pronation  maintained  by  the  spasm  of  the 
peronei  muscles.  These  tendons  must  first  be  lengthened 
by  tenotomy  or  better  by  tenoplasty.  The  latter  is  done 
by  two  transverse  cuts  from  opposite  sides  of  the  tendon 
extending  halfway  through  and  then  stretching  it  until  it 
tears  within  its  sheath,  giving  the  desired  and  usually 
permanent  lengthening.  Put  up  in  plaster  and  treat  as 
above.  * 

(e)  Claw.  This  condition  is  always  progressive, 
usually  rapidly  so,  and  is  a  cause  for  rejection  from  the 
service.  Several  varieties  are  described.  First  Degree : 
(a)  First  toe  contracted,  (b)  the  other  toes  contracted, 
(c)  all  contracted.  Second  Degree :  An  intensification  of 
the  first,  with  marked  varus  of  the  os  calcis,  callosities 
and  short  tendo  Achillis.  Third  Degree  (Jones'  Fifth 
Degree) :  Intense  neuro-vascular  changes,  with  blisters, 
blebs  and  gangrene.  Sometimes  also  deep-seated,  painful 
callosities  and  corns.    Treat  by  the  palliative  methods 


FOOT  STRAIN  223 

given  with  a  great  deal  of  dry  hot  air.  The  first  degree 
may  be  relieved  by  fasciotomy  and  tenoplasty.  Lift  up 
the  heads  of  the  metatarsal  bones  by  fixing  the  extensor 
tendons  to  the  heads  of  the  phalanges.  Occasionally  the 
flexor  tendons  are  fixed  to  the  proximal  heads  of  the 
phalanges.  In  the  second  degree  operate  at  once.  In  the 
third  degree  it  may  be  necessary,  because  of  the  poor  cir- 
culation, to  amputate  the  toes  or  to  perform  an  astraga- 
lectomy. 

Acute  Foot  Strain.  This  condition  occurs  most  often 
in  the  new  recruit,  and  is  treated  by  rest  in  the  recum- 
bent position.  The  pain,  swelling  and  tenderness  rapid- 
ly subside  when  massage,  passive  movements,  active 
movements  without  weight  bearing,  and  finally  walking 
are  resumed  as  soon  as  they  can  be  done  without  pain. 
In  the  more  severe  types  strap  with  double  stirrup- 
strapping  or  partial  figure-of-eight  already  described,  or 
else  place  in  the  corrected  position  with  knee  flexed,  and 
apply  a  plaster  of  Paris  splint,  from  the  toes  to  the  mid- 
dle of  the  thigh. 

Chronic  Foot  Strain.  Here  the  onset  is  slower.  The 
typical  symptoms  are  the  pain  and  stiffness  on  first  get- 
ting onto  the  feet  in  the  morning,  which  may  return 
toward  night  with  fatigue  of  the  muscles.  Change  the 
occupation  so  as  to  relieve  the  feet  from  strain.  Order 
proper  shoes,  strapping,  or  arch  if  necessary,  and  treat 
as  above. 

Hammer  Toe.  Never  amputate  for  this  condition ;  re- 
member that  every  toe  in  its  normal  position  contributes 


224 


ORTHOPEDICS 


to  the  lateral  support  of  the  others.  If  due  to  habit,  it 
may  be  corrected  by  strapping  from  base  to  tip,  running 
under  the  adjoining  toes  and  over  the  hammer  toe.  Cut 
the  flexor  tendon  if  necessary. 

Corrective  Appliances  for  Shoes.  In  the  Army  no  re- 
movable appliance  may  be  worn  by  men  on  active  duty. 
An  intensive  study  of  the  methods  by  which  the  shoe 
itself  may  be  altered  by  any  cobbler  has  been  most  suc- 
cessful in  its  results. 


(A)  Long  inner  wedge  inserted,  between  the  layers  of  the  sole,  to  help 
Bupinate  the  foot  extended  under  the  first  four  metatarso-phalangeal  joints. 

(B)  The  "D"  shaped  wedge  of  Jones  for  the  same  purpose. 

(C)  The  Thomas  Heel.    "C"  the  higher  (%  to  %  inch)  inner  side  for 
eversion.    **Cr"  the  flare  on  the  inside  of  the  heel  to  add  stability. 

(D)  Jones  across  bar  now  inserted  between  the  layers  of  the  sole  for 
anterior  arch  trouble. 

(E)  Steel  insert  to  prevent  weak  shank  from  adding  to  foot  strain  on 
rough  ground. 


TREATMENT   OF   MINOR  FOOT   AILMENTS 

Synovitis  of  Anterior  Tendons.  Lace  the  shoes  only 
with  the  broad  ribbon  laces  laid  flat.  At  the  fifth  holes 
carry  lacer  through  twice  to  retain  snugness  below,  and 
prevent  the  foot  going  forward  in  the  shoe.  Above  the 
fifth  eyelets  lace  loosely  and  tie  behind  so  puttees  do  not 
press  on  knot.    Massage  (effleurage  upward),  rest,  bake 


FOOT  STRAIN  225 

or  paint  with  iodine,  for  curative  treatment.  Watch  for 
and  treat  constitutional  disorders. 

Blisters,  (a)  Small  superficial  type,  open  with  sterile 
needle  at  periphery  if  desired.  Place  pad  on  sticky  side 
of  plaster  directly  over  the  blister,  and  strap  tightly  to 
promote  absorption,  (b)  Deeply  inflamed  type.  Clean 
hands  and  area  carefully.  Open  at  periphery  with  sterile 
needle  or  bistoury.  Press  out  all  exudate.  Paint  with 
iodine  or  ambrine,  pad  and  strap  tightly.  Be  careful  al- 
ways not  to  break  the  skin  on  top  of  the  blister. 

Abrasions.  Disinfect  with  iodine  or  alcohol.  Pad 
and  strap  if  caused  by  puttee  or  knotted  laces,  readjust 
shoe  lace  as  above  indicated. 

Fissures.  Clean  out  superficial  ones  with  iodine  21/^ 
per  cent,  pad  and  strap.  Cauterize  deep  ones  with  silver 
nitrate,  pad  and  strap. 

Over-Riding  Toes.  These  are  not  important  except  for 
the  liability  of  corn  formation,  and  can  be  neglected. 

Corns.  No  man  in  the  service  is  allowed  to  have  his 
corns  cut  or  pared.  Their  deep  and  irregular  under  sur- 
face makes  the  liability  to  infection  very  great.  Eemove 
the  cause,  which  is  generally  pressure  by  improperly  fit- 
ting shoes.  Clean  and  dry  the  corn  and  apply  the  stand- 
ard corn  collodion.  Dress  with  gauze  and  reapply  every 
other  night  for  six  to  ten  days ;  after  a  thorough  soaking, 
the  com  can  then  be  lifted  out  in  its  entirety  by  some 
blunt  instrument.    Fulguration  will  usually  cure. 

Soft  Corns.  Clean  carefully,  apply  corn  salve,  cov- 
ered by  a  pledget  of  wet  gauze,  bring  the  toes  together 


226  ORTHOPEDICS 

and  strap  them;  bathing  the  feet  frequently  with  cold 
water  and  proper  shoes  will  prevent  their  formation. 

Callosities.  Soak  with  water,  scrape  and  apply  com 
salve.  Chromic  acid  or  excision  may  be  necessary  for  the 
removal  of  deep  ones. 

Warts.  These  growths  are  of  great  importance,  as  the 
pain  from  even  a  very  small  one  may  cause  foot  strain  in 
the  effort  to  avoid  weight  bearing  on  them.  They  are  es- 
sentially fungi,  have  hard  glistening  surfaces  and  dark 
spots  in  them.  Ring  them  with  vaseline  or  other  grease 
and  paint  with  glacial,  acetic  or  nitric  acid.  Dress  and 
strap,  treating  the  same  number  of  times  as  directed  for 
corns.  Fulgurate  with  high-frequency  current  if  neces- 
sary. 

Sweating  Feet.  This  condition  is  a  great  source  of 
danger  to  the  soldier.  Daily  cold  water  baths  should  be 
used.  Rub  with  10  per  cent  salicylic  acid  in  alcohol. 
Dry  and  apply  1-1000  potassium  permanganate,  10  per 
cent  formalin,  or  25  per  cent  aluminum  chloride.  The 
sock  may  be  dipped  in  1-2000  bichloride  and  dried.  Treat 
daily  with  foot  liniment. 

Chilblains.  In  mild  cases  stimulate  by  friction,  foot 
liniment  and  frequent  changes  of  dry  woolen  socks.  The 
severe  cases  demand  only  cold  applications,  rest  and  ele- 
vation.   No  massage  or  heat  should  be  used. 

Trench  Foot.  The  phenomenon  is  similar  to  the  effect 
of  frost-bite  and  was  formerly  common.  When  proper 
precautions  are  taken  it  is  largely  preventable  at  the 
present  time.  The  cause  is  cold,  wet  and  interference 
with  the  circulation.    The  onset  is  gradual,  characterized 


FOOT  STRAIN  227 

by  chilling  and  numbness.  There  is  no  pain  at  first. 
Later  on  swelling  of  the  feet  and  marked  pain  develop 
where  the  blood  still  circulates  sluggishly  just  above  the 
affected  area.  Treatment  is  aimed  largely  at  prevention 
by  cleanliness,  oiling  and  several  pairs  of  clean  dry 
socks,  with  the  outer  coverings  of  the  foot  and  leg  loosely 
applied.  It  was  aimed  to  keep  the  trenches  as  dry  as 
possible,  the  feet  and  toes  in  constant  motion,  and  not  to 
allow  the  shrinking  of  wet  leggins  to  constrict  the  leg. 
Foot  coverings  were  removed,  dried  with  hot  pebbles  or 
oats,  the  feet  rubbed  and  again  covered.  Warm  drinks 
and  dry  garments  are  factors  of  importance  in  preven- 
tion. Treat  by  elevation  with  exposure  to  sun  and  air. 
Electric  light  baths  followed  by  massage  when  the 
oedema  lessens.  Aspirate  bullae  if  present,  and  give  anti- 
tetanic  serum  if  the  feet  have  been  abraded.  Morphine 
is  indicated  where  the  pain  is  severe. 

Shoe  Fitting.  No  study  of  foot  ailments  is  complete 
without  a  consideration  of  that  greatest  of  all  factors  in 
their  avoidance,  namely,  proper  shoes. 

The  Munson  last  with  its  straight  inner  line  and  broad 
toe  provides  the  best  shoe  for  men.  In  the  Army  the 
recruit  is  fitted  as  follows : — He  stands  on  the  rule  on  his 
left  foot,  with  forty  pounds  on  his  back.  His  foot  length 
is  then  determined  and  he  is  given  the  second  larger  size. 
The  width  is  determined  by  a  scale  from  the  circumfer- 
ence of  the  fore  foot  at  its  broadest  part.  After  six 
months  his  strengthened  foot  muscles  require  refitting  of 
his  shoes. 

When  the  shoe  is  on  and  his  weight  all  on  the  left  foot, 


228 


ORTHOPEDICS 


PRESCRIPTIONS 


Com  Collodion 

Salicylic  Acid   11  parts 

Ext.  Cannabis  In- 
dica   2  parts 

Alcohol.  95  per  cent.    10  parts 

Flexible  Col- 
lodion     ad  100  parts 

Stimulating  Limment 

Chloroform 1  part 

Spirits  of  Tur- 
pentine   31/2  parts 

Olive  Oil 31/2  parts 

Oily  Liniment  for  Sweating 

Methyl  Salicylate 
or  Oil  Wintergreen. . .  2  oz. 

Carbolic  Acid   1  dr. 

Camphor, 
Chloral, 

Menthol aa  2  dr. 

Spirits  of  Turpentine . .  4  dr. 
Alberine   Oil q.s.  ad  8  oz. 


Com  Sc^ve 


Salicylic  Acid    40  parts 

Vaseline 30  parts 

Lanolin    30  parts 


Aqueous  Liniment  for 
Sweating 

Salicylic  Acid 3  dr. 

Camphor, 

Carbolic  Acid aa  30  gr. 

Dissolve  in  Alcohol  95 
per  cent.,  add  3  oz. 
Glycerine 1  oz. 

Ext.  Hamamelis 4  oz. 

Alum,  pulv 4  dr. 

Aquae q.s.  ad  12  oz. 


there  should  be  spare  length  of  about  the  breadth  of  the 
forefinger  in  front  of  the  longest  toe.  The  leather  over 
the  dorsum  should  just  wrinkle  but  not  enough  to  be 
grasped  by  the  fingers. 


Chapter  XTV 

BEACES  AND  CASTS 

Braces.  A  good  generalization  on  the  theory  of  the 
treatment  of  orthopedic  defects  by  braces  is  hard  to  find 
in  the  literature.  The  descriptions  of  use  of  different 
types  of  braces  in  the  various  deformities  are  scattered 
throughout  the  text  books,  and  the  application  of  the 
same  general  principles  in  each  case  is  often  obscure. 
This  failure  to  grasp  the  fundamental  principles  has  been 
evident  in  some  of  our  army  orthopedic  instruction  as  is 
stated  by  Major  R.  W.  Lovett,  of  Boston.  He  says: 
''The  student  as  a  rule  is  taught  that  a  certain  splint  is 
used  for  tuberculosis  of  the  hip,  another  for  Pottos  dis- 
ease, another  for  club  foot  and  a  fourth  for  flat  foot.  He 
does  not  connect  these,  nor  does  he  understand  their  prin- 
ciples very  well,  and  as  a  rule  speedily  forgets  all  about 
them  except,  perhaps,  the  name.  It  has  been  found  pos- 
sible to  get  some  knowledge,  apparently  more  permanent, 
into  the  minds  of  the  students  by  a  different  method  of 
approach.  It  is  taught  that  apparatus  may  be  of  wood, 
plaster,  iron,  tin,  leather  and  other  materials;  that 
crutches  are  apparatus  and  so  are  ham  splints ;  that  ap- 
paratus should  be  used  for  a  definite  mechanical  purpose, 
and  that  if  the  student  does  not  understand  what  he  is 

trying  to  do,  he  will  probably  not  fit  satisfactory  braces ; 

229 


230  ORTHOPEDICS 

that  apparatus  is  used  for  four  purposes:  (1)  fixation, 
(2)  traction,  (3)  support  or  protection,  and  (4)  correction 
of  deformity.  A  case  is  shown,  its  pathology  analyzed, 
and  its  mechanical  needs,  if  any,  are  formulated.  It  may 
require  the  application  of  one  of  the  four  purposes  de- 
scribed above,  and  if  so  the  student  is  required  to  work 
out  the  mechanical  needs  without  calling  apparatus  by 
name.  He  is  asked  to  work  out  in  wire  or  paper  or  on  the 
blackboard  the  theory  of  the  required  apparatus.  He  is 
then  requested  to  state  practically  how  it  could  be  done  in 
plaster,  leather  or  metal,  and  he  is  then  made  familar 
with  the  accepted  splint  to  meet  that  need.  The  response 
of  students  to  this  method  of  instruction  has  in  this  de* 
p^rtment  been  most  satisfactory. ' '  * 

The  same  broad  treatment  of  the  question  of  braces 
and  splints  was  being  taught  by  Major  E.  S.  Geist,  M.  C, 
U.  S.  A.,  at  Camp  Greenleaf .  A  set  of  simple  tools,  which 
he  has  devised  and  called  the  ** Oglethorpe  Kit,"  with 
bench  and  vise,  was  sufficient  for  the  improvisation  of 
many  splints  from  wire,  which  he  found  to  be  a  most  use- 
ful material.  For  the  heavier  braces  a  blacksmith's  tools 
are  necessary.  Provision  for  lengthening  each  type  of 
the  various  braces  here  described  should  always  be  made, 
except  in  the  case  of  adults. 

Arch  braces  are  described  under  the  topic  of  flat  foot. 

Talipes  Calcaneus.  This  brace  consists  of  two  lateral 
bars  curved  forward  to  about  an  angle  of  130  degrees  at 
the  external  malleolus,  joined  in  front  and  below  by  a  thin 

*  A  System  of  Orthopedic  Instruction,  American  Journal  of  Orthopedic 
Surgery,  August,  1918,  page  487. 


BRACES  AND  CASTS  231 

eole  plate  and  above  by  a  leather  cuff.  Complicated  by 
valgus  or  varus,  the  deformity  is  checked  by  a  plate  under 
the  sole  and  over  the  edge  of  the  foot. 

Knee.  For  arthritis,  or  ligament  strain  about  the  knee 
joint,  the  best  brace  is  a  simple  hinge,  locked  against  over- 
extension and  supported  by  a  broad  leather  cuff  on  th^ 
tipper  curve  of  the  calf  and  lower  half  of  the  thigh. 

For  tubercular  knee,  the  best  brace  is  the  Thomas 
splint,  consisting  of  two  side  bars  extending  below  the 
shoe  and  joined  by  a  cross  bar,  which  acts  as  a  stilt.  It  is 
joined  together  above  by  a  padded  ring,  which  fits  snugly 
at  the  upper  part  of  the  thigh,  this  ring  so  inclined  that 
the  weight  is  evenly  distributed.  Certain  common  modi- 
fications allow  for  active  extension  of  the  knee  by  means 
of  moleskin  plaster  and  buckles  and  various  other  me- 
chanical means. 

The  caliper  splint  of  Ridlon  and  Jones  is  used  in  the 
recovery  stage,  and  is  so  arranged  that  a  gradually  in- 
creasing amount  of  weight  can  be  borne  upon  the  foot. 

The  bow-leg  brace  consists  of  a  strong  inside  column 
and,  occasionally,  a  lighter  external  one  with  cross  bar 
through  the  heel  of  the  shoe.  There  is  a  hinge  at  the 
ankle  joint  and  a  posterior  band  above,  curved  obliquely 
upward  and  outward  to  the  great  trochanter.  A  short, 
hinged,  vertical  piece  from  this  point  is  connected  with  a 
waist  strap.  Two  broad  cuffs  on  the  thigh  and  calf  exert 
traction  toward  the  strong  inner  bar.  There  is  a  modifi- 
cation of  this  long  brace  by  Napier  and  a  short  Knight 
bow-leg  brace. 

The  knock-knee  brace  of  the  Thomas  and  other  types 


232  ORTHOPEDICS 

are  very  similar,  with  the  strong  supporting  column 
hinged  at  ankle  and  hip  on  the  outer  side.  There  is  not 
usually  an  inner  support. 

Leg.  Infantile  leg  braces  are  similar  to  the  last  two 
types  described  with  the  exception  that  they  have  two 
firm  lateral  supports  usually  hinged  at  the  hip  and  at  the 
knee,  with  a  lock  which  the  patient  may  manipulate.  A 
hinge  at  the  ankle  is  locked  against  extension,  and  an 
arch  plate  fits  inside  the  shoe. 

Bach.  Back  braces,  for  use  largely  in  tuberculous 
spine,  consist  of  two  strong  bands  of  steel  shaped  to  the 
contour  of  the  spine  from  the  bony  pelvis  to  the  neck,  with 
a  semi-circular  steel  hip  band  and  a  front  canvas  apron, 
cut  to  fit  the  chest  and  abdomen  firmly.  A  head  support 
by  means  of  a  ring  around  the  chin  or  a  jury-mast  over 
the  head  with  a  sling  is  indicated  where  surgical  lesions 
are  present. 

Casts.  Plaster-of-Paris  as  a  means  for  securing  well 
fitted  support,  protection  and  extension,  is  worthy  of  a 
wider  use  in  general  practice  than  it  has  yet  attained.  Its 
ease  of  application,  quick  setting  and  the  convenience 
with  which  it  can  be  carried  are  greatly  in  its  favor. 

Plaster  bandages  are  easily  prepared  at  home  by  cut- 
ting long  strips  of  coarse  muslin  or  crinoline  to  the  de- 
sired width  of  two,  four,  or  six  inches.  White  plaster  is 
best,  but  gray,  coarse  plaster  is  serviceable.  It  should  be 
rubbed  thoroughly  into  the  meshes  of  the  cloth,  which  is 
tightly  rolled  as  you  go  along,  and  then  kept  in  a  moisture 
proof  metal  or  glass  container.  "Wide  bandages  when  well 
rolled  are  easily  cut  by  a  plaster  knife. 


BRACES  AND  CASTS  233 

It  is  impossible  to  avoid  some  spreading  of  the  plaster 
in  rapid  work,  so  the  clothing  and  floor  should  be  prop- 
erly protected.  The  skin  should  be  cleansed  with  warm 
water  and  soap,  or  alcohol,  dried  and  then  powdered. 
Any  abraded  surface  should  be  covered  with  sterile  gauze 
and  later  a  window  cut  through  the  cast  at  that  point. 
The  part  to  be  incased  should  be  wrapped  in  some  soft 
material,  cotton  roller  bandage,  a  thin  layer  of  cotton, 
jersey  or  other  material.  A  felt  jacket  may  be  used  for 
the  body.  Joints  and  points  of  pressure  need  extra 
padding.  Crushed  tissue  paper  or  even  newspaper  is  of 
service  here.  The  bandage  is  then  immersed  in  warm 
water  for  twenty  or  thirty  seconds  or  until  bubbling  has 
ceased,  when  it  should  be  picked  up  with  the  open  ends 
against  the  palms  of  the  hands,  and  excess  of  water 
gently  squeezed  out.  This  hold  prevents  undue  loss  of 
plaster.  The  surgeon  should  protect  his  hands  if  possi- 
ble, with  cheap  rubber  gloves.  If  this  is  not  possible  pro- 
tect the  under  side  of  the  nails  by  filling  them  with  soap 
or  cold  cream.  Plaster  is  easily  removed  by  the  use  of 
a  little  sugar  or  com  meal. 

The  part  is  held  in  the  desired  position  by  an  assistant 
until  after  setting  is  fairly  complete,  the  bandages  being 
applied  in  the  same  manner  as  in  simple  bandaging.  It  is 
often  desirable  to  increase  the  rigidity  of  the  cast  by 
rubbing  in  dry  plaster  scattered  over  the  surface  during 
the  application.  Another  means  of  strengthening  a  weak 
point  is  by  doubling  the  bandage  back  and  forth  and  over- 
laying it  again  with  circular  strips. 

In  club  foot  and  several  other  conditions  there  is 


234  ORTHOPEDICS 

plenty  of  time  to  secure  the  correction  after  the  cast  has 
been  applied,  maintaining  it  during  setting.  With  an  in- 
delible pencil,  while  the  cast  is  still  wet,  the  upper  and 
lower  edges  and  any  desired  windows  can  be  marked  and 
then  cut.  Some  surgeons  insert  at  the  beginning  a  sheet 
of  tin  or  other  substance  upon  which  to  cut  down  when  the 
time  comes  for  removal.  With  care  and  a  little  skill  in 
cutting  this  is  usually  unnecessary.  Two  vertical  and 
parallel  cuts  a  quarter  of  an  inch  apart,  with  the  free  use 
of  vinegar,  in  an  old  cast  make  removal  fairly  easy.  All 
wounds  are  dressed  through  sufficiently  large  windows. 
The  extremities,  toes  and  finger  tips  should,  when  pos- 
sible, be  exposed  as  a  guide  to  the  condition  of  the  cir- 
culation under  the  cast.  X-rays  are  usually  more  read- 
able through  casts  than  through  many  of  the  common 
prepared  splints.  See  that  the  edges  are  rounded  and 
well  padded  in  such  places  as,  for  instance,  the  axilla. 


GLOSSARY 

TISSUl! ;  NAMa  PERTAININQ  TO 

arthral joint 

cardiac heart 

carpal     .    » wrist 

colonic large  intestine 

enteric     .......  small  intestine 

gastric .  stomach 

genu knee 

hallux great  toe 

hemal,  hsemal hlood 

jnyo muscle 

nephric kidney 

neural nerve 

osteo bone 

pedal fooi 

synovial membrane  (joint) 

talipes foot  deformity 

tarsal ankle 

teno-synovial membrane  (tendon) 

POSITIONS 

abduction owO'V  from  the  body 

adduction toward  body 

calcaneus ^^  ivalking 

equinous *o«  viking 

epi 


supra 


.     above 
235 


236  OETHOPEDIOS 


"below 


infra 
sub 

end— endo inner 

peri outer 

prone /oice  or  pcdm  down 

supine face  or  palm  up 

'I  ...  aiway  from  center  of  body 

peripheral  J 

proximal toward  center  of  body 

cervical neck  vertebrce — seven 

I chest  vertebrcB — twelve 

dorsal  j 

lumbar abdominal  vertebrce — five 

valgus turned  in 

varus turned  out 

SUFFIXES 

algia  .    ,' pojln 

eetomy to  cut  out 

itis inflammation,  of 

osteomy to  leave  opening  into 

otomy to  cut  into 

SPINE 

kyphosis increased  dorsal  curve 

lordosis increased  lumbar  curve 

scoliosis rotary  lateral  curve 

torticollis    ......  urry  neck 


INDEX 


Abbott  jacket,  129 
Abrasion  on  feet,  225 
Abscess,  bone,   149 
Acromioclavicixlar  joint,   dislocation 

of,  153 
Acromion  process,  fractures  of,  154 
Adhesions,  after  treatment,  139 

—  breaking  down,  70 
Ankle,  after  treatment,  203 

—  complications,  203 

—  dislocations,   203 

—  fractures,  202 
Pott's,  202 

—  sprains,  139 

—  strains,  139 

Ankylosis,    best   position    in    ankle, 
202 

elbow,  174 

hip,  192 

knee,  198 

shoulder,   165 

Apparatus,  gymnastic,  19 

—  occupational  therapy,  82,  85 

—  physiotherapy,  25,  30 

Arm,    exercises,    infantile,    98,    99, 

100 
general,  19 

—  joint  mobilization,  20 
Arch,  anterior,  216 

—  exercises  for,   216 

—  hammock,    215 

—  steel,  212 

Arthritis,  acute  rheumatic,  142 

—  atrophic,    141 

—  deformans,  140 

—  degenerative,  140 

—  gonorrheal,  144 

—  hypertrophic,  141 

—  osteoarthritis,  143 

—  proliferative,  140 

—  rheumatoid,    140 
' — spondylitis,   140 

—  syphilitic,  144 

—  toxic,  140 

—  traumatic,  139 

—  tubercular,  142 
Articular  cartilages,  135,  197 


Articular  injuries,  135 

—  operation,  136 

—  treatment,  136 
Astragalus  fractures,  203 

—  dislocations,   203 

Back,  massage  of,  53 

Baking,   physiological   effects,   27 

—  technique,  28 
Bandaging,  233 
Baths,  cabinet,  30 

—  contrast,  34 

—  electric,  30 

—  whirlpool,  34 
Bone,  diseases  of,  146 

—  osteitis,  149 

—  osteomalacia,  150 

—  osteomyelitis,  149 

—  periostitis,   146 

—  repair  in,  146 

—  rickets,  92 

—  tuberculosis,  151 
Bow-legs,  231 
Braces,  229 
Brachial  plexus,  104 

injuries  to,  104 

Bradford  frame,  181 
Bunion,  220 
Bursitis,  71 

Callosities,  226 

Cartilage   {See  Articular),  135,  147 

Cell,  galvanic,  39 

Chilblains,    226 

Circumflex   nerve  paralysis,    104 

Club-foot,  91 

Contracture,  14 

Corns,  225 

Coxa  vara,  92 

Deltoid-paralysis,  104 

Diathermy,  44 

Dislocation,  acromioclavicular,  153 

—  ankle,  203 

—  elbow,  170 

—  hip,  186 


237 


238 


INDEX 


Dislocation,  knee,  197 

—  shoulder,  157 

—  vertebrae,  110 

—  wrist,   178 
Douche,  Scottish,  34 
Drop-foot,  105 
Drop-wrist,  103 

Effleurage,  technique,  54 

—  uses,  57 

Elbow,  adhesions,  169 

—  ankylosis,  173 

—  dislocations,    170 

—  fractures  about,  169 
Exercise,  arch,  216 

—  athletic  training,  4 

—  fatigue  in,  2 

—  relation  to  age,  9 

—  relation  to  sex,  8 

—  safeguards,  4 

—  settiQg-up  drill,  17,  18 

—  spinal  curvature,  117,  118 

—  types,  9 

endurance,  9 

skill,  9 

speed,  9 

strength,  9 

Faradism,  40 

Fatigue,  10 

Femur,    fractures    of    lower    third, 

194 

middle  third,  193 

upper  third,  192 

Fibula,    fractures    of    lower  third, 

202 

middle  third,  201 

upper  third,  198 

Fixation,  plaster,  222 

—  splints,  230 

Foot,  anterior  metatarsalgia,  216 

—  deformities  of,  219 

—  flat-foot,  205 

acute  strain,  223 

chronic  strain,  223 

flaccid  flat,  221 

plates  for,  212 

rigid,  222 

shoes,  modifications  of,  224 

spastic,  222 

Fractures,  after  treatment,  69 

—  carpus,  178 

—  clavicle,  152 

—  Colles,  177 

—  complications,  149 

—  femur,  192 


Fractures,  fibula,  202 

—  foot,  204 

—  hand,    178 

—  humerus,  161 

—  olecranon,  169 

—  patella,  195 

—  Pott's,  202 

—  radius,  177 

—  scapula,  153 

—  semilunar,  197 

—  spine,   110 

—  tarsus,   203 

—  tibia,  198 

—  ulna,  177 

Frame,  abduction,  184 

—  Bradford,  181 

—  suspension,  181 
Friction,  61 

Galvanism,  39 
Graft,  bone,  108 
Gymnastics,  medical,  10 

—  re-educational,  99 

Hallux  rigidus;  operations  for,  223 

valgus,  222 

Hammer  toe,  223 

Health,  dependence  on  muscle  func- 
tion, 1 
Heart,   exercises,    7 
High  frequency,  43 
Hibbs'  table,  192 
Hip,  abduction,  splint  for,  184 

—  ankylosis,  position  for,  186 

—  braces,  232 

■ — coxa  vara,  93 

—  dislocations  of,  186 

—  fractures  of,  191 
Hydrotherapy,    physiological    effect 

of,  29 

—  technique,  33 

—  types  of  baths,  34 
Hyperaemia,  active,  27 
• — passive  (Bier's),  28 

Ionization,  40 
Ischemic  paralysis,  177 

Joints,  ankylosis,  positions  for,  202 

—  flail,  136 

—  injuries  to,  135 

' — massage  of,  139 

—  mobilization  of,  138 

Knee,  adhesions,  195 

—  ankylosis,  19^ 


INDEX 


239 


Knee,  bursitis,  71 

—  dislocations,  197 

—  fractures  about,  195,  197 

—  internal  injuries,  197 

—  rupture  of  crucial  ligaments,  198 

—  semilunar  cartilages,   197 

—  synovitis,  69 
Knock-knees,  92 
Kjphosii,  exercises,  117,  118 

Leg,  exercises,  101 
Ligaments,  injuries,  136  , 

—  treatment,   138  >• 
Lordosis,  exercises,  120,  121 

Massage,  contraindications,  63 

—  indications,  54 

—  technique,  54-62 

—  types,  46 
Mechanotherapy,  131 
Median  nerve,   104 
Metatarsalgia,  216 
Mirror,  use  in  exercise,  114 
Movements,  passive,  assistive,  aetire, 

resistive,  13 
Muscle  atrophy,  103,  104 

—  balance,  14 

—  contracture,  14 

—  degeneration,  177 

—  electrical  stimulation,  39 

—  fatigue,  17 

—  massage,  57 

—  tonus,  14 
Musculocutaneous,  104 
Musculospiral,  104 

Nauheim  exercises,  10 
Nerve  injuries,  central,  93 

peripheral,   103,   104 

scarg,  adherent  to,  105 

Occupational  therapy,  79 
Osteitis,   149 
Osteogenesis,  150 
Osteomalacia,  150 

Pain,  massage,  guide,  49 

—  passive  movement,  guide,  13 

—  scars,  62 
Paralysis,  flaccid,  97,  103 

—  infantile,  97 

—  spastic,  93 

—  traumatic,  104 
Passive  movements,  13 
Peronei,  transplantation  of,  103 


Petrissage,  57 

Phalanges,  dislocation,   178,  204 

—  fractures,  178,  204 
Physiotherapy,  27 

Plaster  of  paris,  application,  232, 233 

preparation,  233 

Popliteal  nerve,  paralysis  of,  104 
Pott's  disease,  107 
Prescriptions,  foot  ailments,   228 
Pulley  weights,  exercises,  17-24 

Badiant  heat,  27 
Reconstruction,  10 
Ee-education,  97 

—  muscle,  10 

—  physical,  17,  222 

—  vocational,  79 
Bheumatism,  140 
Eickets,  92 

Sacroiliac  lesions,  112 

—  strapping,   112 

Scar  tissue,  contractures,  62 

massage,  61 

pain  in,  62 

—  —  stretching  of,  13 
Scoliosis,  braces,  129 

—  diagnosis,   127 

—  exercise  programs,  130 

—  prognosis,  130 

—  types,  123 

Septic  wounds,  Carrel-Dakin,  150 

massage,  57 

• violet  ray,  44 

Shoe,  fitting,  227 

—  modifications  of  for  foot  deform- 

ities, 224 
Shoulder,     ankylosis,    position    for, 
165 

—  dislocations,  157 

—  exercises  for  deformities,  18 

—  fractures  about,  162 
Sinusoidal  current,  43 
Spine,  arthritis,   140 

—  braces,  232 

—  casts,  232 

—  dislocations,  110 

—  fractures,  110 

—  kyphosis,  113 

—  lordosis,  119 

—  torticollis,   110 

—  tuberculosis  of,  107 

Splints    {See  also  Braces),  caliper, 
192,  231 

—  humeral  extension,   166 

—  Jones'  cockup,  105 


240 


INDEX 


Splints,  Thomas  leg,  231 

—  wire  cockup,  103 
Sprains,   diagnosis,  137 

—  treatment,   138 
Static  electricity,  44 
Strapping,  back,  112 

—  flat  foot,  211 

—  metatarsalgia,  216 

—  sprains,    138 
Stumps,  massage  of,  75 

—  preparation  for  prothesis,  76 
Sun  lamp,  44 

Synovitis,  treatment  of,  69,  224 

Tapotement,    contraindications,    58 

—  technique,  61 
Tarsus,  injuries  to,  203 

—  treatment  of,  203 
Tendons,  massage  of,  68 

—  tenoplasty,  222 

—  tenosynovitis,  69 

—  tenotomy,  222 

—  transplantation,  103 
Thermolight,  27 
Thermaphore,  27 


Thomas  heel,  224 
Thomas  splint,  arm,  161 

leg,  231 

Tibial  nerve,  paralysis  of,  anterior, 

105 

posterior,  105 

Trench  foot,  226 

Tuberculosis     {See     Arthritis     and 

Bone),  142,  151 

Ulnar  nerve,  paralysi*  of,  104 

Varicose  veins,  massage  of,  64 
Vertebrae  (See  Spine),  106 
Vibration,  manual,  61 

—  mechanical,  61 
Vocational  reconstruction,  106 
Volkmann's  contracture,  177 

Whirlpool  bath,  34 
Whitman  arch  plate,  215 
Wrist,  drop,  103 

—  exercises  for,  103 

—  injuries,  177 

—  treatment,  177 


Paul  B.  Hoeber,  67-71  East  69th  Street,  New  York 


HOEBER'S 
MEDICAL  MONOGRAPHS 


MEDICAL  MONOGRAPHS 

Published  by 

PAUL  B.  HOEBER 

67'69'7i  East  59th  St.,  New  York 

This  catalogue  comprises  only  our  own  publications.  It  will 
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ADAM:     Asthma   and    Its    Radical    Treatment.     By  James 
Adam,  m.a.,  m.d.,  f.r.c.p.s.    Hamilton.    Dispensary  Aural  Sur- 
geon, Glasgow  Royal  Infirmary. 
8vo.     Qoth,  viii+184  pages,  Illust net  $1.75 

ADLER:    Compendium  of  Histo-Pathological  Technic.     By 
Emma  H.  Adler.     Formerly  Technician  Pathological  Labora- 
tory, Presbyterian  Hospital,  New  York. 
12mo.    Cloth  net  $125 

ADLER:    Primary  Malignant   Growths   of  the   Lungs   and 
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Polyclinic,    Consulting    Physician,    German,    Beth-Israel,    Har 
Moriah,  People's  and  Montefiore  Hospitals. 
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AMERICAN  JOURNAL  OF  ROENTGENOLOGY,  THE. 
Official  Organ  of  the  American  Roentgen  Ray  Society.   Edited 
by  H.  M.  Imboden,  m.d..  New  York. 
Published  monthly.    Vol.  VI,  No.  1,  Jan.,  1919. .  .$6.00  per  year. 

ANATOMICAL  CHARTS,     {^ce  BLAINE.) 

ANNALS  OF  MEDICAL  HISTORY.  Edited  by  Francis 
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George  Dock,  Fielding  H.  Garrison,  Howard  A.  Kelly,  Sir 
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ARMSTRONG:  I.  K.  Therapy,  with  Special  Reference  to 
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Bacteriologist  to   Cent.   Lond.   Ophthalmic   Hosp.,   Late   Asst. 

I 


2  HOEBER'S  MEDICAL  MOHOGRAPHS 

in  Inoculation  Dept.,  St.  Mary's  Hosp.,  Paddington,  W. 
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BACH:    Ultra-Violet   Light  by  Means  of  the  Alpine   Sun 
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BARRINGER,  JANE  WAY  AND  FAILLA:  Radium  Ther- 
apy in  Cancer  at  the  Memorial  Hospital.  (See  Janeway, 
Barringer  and  Failla.) 

BIGG:     Indigestion,  Constipation  and  Liver  Disorder.     By 
G.  Sherman  Bigg,  Fellow  of  the  Royal  College  of  Surgeons; 
Fellow  of  the  Royal  Institute  of  Public  Health;  Late  Surgeon 
Captain,  Army  Medical  Staff;  Surgeon  Allahabad,  India. 
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BLAND-SUTTON:  Tumours:  Innocent  and  Malignant. 
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HOEBER'S  MEDICAL  MOXOCRAPHS  3 

BULKLEY:     Cancer:     Its    Cause   and   Treatment,   Volume 
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BULKLEY:  Compendium  of  Diseases  of  the  Skin.  Based 
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sulting Physician  to  the  New  York  Hospital. 
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BULLETIN:    See    Neurological  Bulletin. 

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4  HOEBEKS  MEDICAL  MONOGRAPHS 

CONTRIBUTIONS  TO  MEDICAL  AND  BIOLOGICAL 
RESEARCH:  Dedicated  to  Sir  William  Osler,  in  honor  of 
his  seventieth  birthday,  July  12,  1919,  by  his  pupils  and  co- 
workers. Special  publication  under  the  auspices  of  the  Osier 
•Anniversary  Volume  Committee. 

Two  volumes ;  1300  pages,  125  Illust.,  including  one  steel  en- 
graving of  Sir  William  Osier,  and  5  colored  pi.  Sold  only  by 
subscription. 

COOKE:  The  Position  of  the  X-Rays  in  the  Diagnosis  and 
Prognosis  of  Pulmonary  Tuberculosis.      By   W.   E.    Cooke, 

M.B.,    M.R.C.P.E.,    D.P.H.     (Lond.). 

8vo.    Cloth,  Illust net  $1.75 

COOPER:      Pathological    Inebriety.      Its     Causation    and 
Treatment.     By  J.  W.  Astley  Cooper.     Medical  Superintend- 
ent and  Licensee  of  Ghyllwood  Sanatorium.     With  Introduc- 
tion by  Sir  David  Ferrier,  m.d.,  f.r.s. 
12mo.     Cloth,  xvi+151  pages net  $1.75 

COOPER:    The    Sexual    Disabilities    of    Man,    and    Their 
Treatment.     By  Arthur  Cooper.     Consulting  Surgeon  to  the 
Westminster  General  Dispensary,  London.    3rd  Edition. 
12mo.     Cloth,  viii+227  pages net  $2.50 

COPESTAKE:  The  Theory  and  Practice  of  Massage.  By 
Beatrice  M.  Goodall-Copestake,  Examiner  to  the  Incorpor- 
ated Society  of  Trained  Masseuses ;  Teacher  of  Massage  and 
Swedish  Remedial  Exercises  to  the  Nursing  Staff  of  the  Lon- 
don Hospital. 
8vo.     Cloth,  284  pages,  Illust net  $3.00 

CORBETT-SMITH:  The  Problem  of  the  Nations.  A  Study 
in  the  Causes,  Symptoms  and  Effects  of  Sexual  Disease,  and 
the  Education  of  the  Individual  Therein.  By  A.  Corbett- 
Smith,  Editor  of  The  Journal  of  State  Medicine;  Lecturer 
in  Public  Health  Law  at  the  Royal  Institute  of  Public  Health. 
Large  8vo.    Cloth,  xii+107  pages net  $1.00 

CORNET:    Acute  General  Miliary  Tuberculosis.     By    Prof. 
Dr.  G.  Cornet,  Berlin.    Transl.  by  F.  S.  Tinker,  b.a.,  m.b. 
8vo.     Cloth,  viii+107  pages net  $1.75 

CROOKSHANK:    Flatulence  and  Shock.    By  F.  G.  Crook- 
SHANK,  M.D.,  Lond.,  M.R.c.p.    Physician  (Out  Patients)  Hamp- 
stead  General  and  N.  W.  Lond.  Hospital. 
8vo.    Cloth,  iv-|-47  pages net  $1.00 

DAVIDSON:    Localization    by    X-Rays    and    Stereoscopy. 
By  Sir  James  Mackenzie  Davidson,  m.b.,  cm.,  Aberd.     Con- 
sulting   Medical    Officer,    Roentgen    Ray    Department,    Royal 
London  Ophthalmic  Hospital. 
8vo.    Cloth,  72  pages,  PI.  and  58  Stereo.    Figures net  $3.00 

DAWSON:    The  Causation  of  Sex  in  Man. By   E.    Rumley 
Dawson,  l.r.c.p.  Lond.,  m.r.c.s.  England. 
8vo.    Cloth,  240  pages,  with  21  Illust net  $3.00 


HOEBER'S  MEDICAL  MONOGRAPHS  5 

DUMAS  AND  CARREL:  Technic  of  the  Irrigation  Treat- 
ment of  Wounds  by  the  Carrel  Method.  (See  Carrel  ^and 
Dumas.) 

ED  RIDGE-GREEN:    The   Hunterian  Lectures   on   Coloiw- 
Vision  and  Colour  Blindness.     Delivered  before  the  Royal 
College  of   Surgeons  of   England   on   February  1st  and  3rd, 
1911.    By  Professor  F.  W.  Edridge-Green,  m.d.,  f.r,c.s. 
8vo.     Cloth,  x+76  pages net  $1.75 

EHRLICH:  Experimental  Researches  on  Specific  Thera- 
peutics. By  Prof.  Paul  Ehrlich,  m.d.,  d.sc.  Oxon.  The 
Harben  Lectures  for  1907  of  Royal  Institute  of  Public  Hfalth. 
16mo.     Cloth,  x+95  pages net  $1.00 

EINHORN:    Lectures  on  Dietetics.    By  Max  Einhorn,  Pro- 
fessor   of    Medicine    at    N.    Y.    Post-Graduate    Med.    School 
and  Hospital,  Visit.  Phys.  German  Hospital,  N.  Y. 
12mo.     Cloth,  xvi+156  pages net  $125 

ELLIOT:    Glaucoma.     By  Col.  Robert  Henry  Elliot,  m.d., 

F  R  C  S 

8vo.    Cloth,  60  pages,  with  23  lUust net  $1.50 

ELLIOT:    Glaucoma.    A  Text  Book  for  the  Student  of  Oph- 
thalmology.   By  Col.  Robert  Henry  Elliot,  m.d.,  f.r.c.s. 
8vo.     Cloth,  546  pages,  156  Illust net  $7.50 

ELLIOT:  The  Indian  Operation  of  Couching  for  Cata- 
ract. Incorporating  the  Hunterian  Lectures  delivered  before 
the  Royal  College  of  Surgeons  of  England  on  February  19 
and  21,  1917.  By  Robert  Henry  Elliot,  m.d.,  b.s.,  Lond., 
sc.D.,  Edin.,  f.r.c.s.,  Eng.,  etc. 
Bvo.     Cloth,  94  pages,  45  Illust net  $3.50 

ELLIOT:    Sclero-Comeal     Trephining     in     the     Operative 
Treatment  of  Glaucoma.     By   Robert   Henry   Elliot,    m.d., 
b.s.   Lond.,  d.sc.  Edin.,  f.r.c.s.   Eng.   Lieut.   Colonel  i.m.s.   2d 
Edition. 
8vo.    Cloth,  135  pages,  33  Illust net  $3.00 

EMERY:    Immunity  and  Specific  Therapy.    By  Wm.  D'Este 
Emery,   m.d.,  b.sc.   Lond.   Clinical  Pathologist  to  King's  Col- 
lege   Hospital    and    Pathologist    to    the    Children's    Hospital. 
Adopted  by  the  U.  S.  Army. 
8vo.    Cloth,  448  pages,  with  2  Illust net  $3.50 

EMERY:    Tumors,  Their  Nature  and  Causation.     By  Wm. 
D'Este  Emery,   m.d.,  b.sc,   Lond.     Director   of  Laboratories, 
King's  College  Hospital,  Captain  r.a.m.c    (T.  F.). 
12mo.    Cloth,  146  pages net  $1.75 

FAILLA,  JANEWAY  AND  BARRINGER:  Radium  Ther- 
apy in  Cancer  at  the  Memorial  Hospital.  (See  Janeway, 
Barringer  and  Failla.) 

FISHBERG:    The  Internal  Secretions.     (See  Gley.) 


6  HOEBER'S  MEDICAL  MOHOGRAPHS 

FRIESNER  AND  BRAUN:  CerebeUar  Abscess;  Its  Eti- 
ology, Pathology,  Diagnosis  and  Treatment.  By  Isidore  Fries- 
NER,  M.D.,  F.A.C.S.,  Adjunct  Professor  of  Otology  and  Assistant 
Aural  Surgeon,  Manhattan  Eye,  Ear  and  Throat  Hospital  and 
Post-Graduate  Medical  School,  and  Alfred  Braun,  m.d.,  f.a.c.s., 
Assistant  Aural  Surgeon,  Manhattan  Eye,  Ear  and  Throat 
Hospital,  Adjunct  Professor  of  Laryngology,  New  York  Poly- 
clinic Hospital  and  Medical  School  and  Adjunct  Otologist,  Mt. 
Sinai  Hospital. 
8vo.    Cloth,  186  pages,  10  pi.,  16  Illust net  $3.00 

GERSTER:     Recollections   of   a   New  York   Surgeon.     By 

Arpad  G.  Gerster,  m.d. 

8vo.     Cloth,  347  pages,  18  Illust net  $3.50 

GHON:    The  Primary  Lung  Focus  of  Tuberculosis  in  Chil- 
dren.    By    Anton    Ghon,    m.d.,    English    Translation    by    D. 
Barty  King,  M.A.,  M.D.  Edin.,  M.C.R.P. 
Large  8vo.    Cloth,  196  pages,  72  Illust.,  2  pi net  $3.75 

GILES :    Anatomy  and  Physiology  of  the  Female  Generative 
*    Organs  and  of  Preg^nancy.      By    jArthur    E.    Giles,    m.d., 

B.sc.    Lond.,    M.R.C.P.    Lond. ;    f.r.c.s.    Ed.    Gynecologist  to   the 

Prince  of  Wales  General  Hospital. 

Large  8vo.    24  pages,  with  Mannikin net  $2.00 

GLEY:    The  Internal  Secretions.     By  K   Gley,   m.d.     Mem- 
ber   of    the    Academy    of    Medicine    of    Paris,    Professor    of 
Physiology  in  the  College  of  France,  etc.     Authorized  Trans- 
lation.    Translated  and  Edited  by  Maurice  Fishberg,  m.d. 
8vo.    Cloth  241  pages net  $2.50 

GREEFF:  Guide  to  the  Microscopic  Examination  of  the 
Eye.  By  Professor  R.  Greeff.  Director  of  the  University 
Ophthalmic  Clinique  in  the  Royal  Charity  Hospital,  Berlin. 
With  the  co-operation  of  Professor  Stock  and  Professor  Win- 
tersteiner.  Translated  from  the  third  German  Edition  by 
Hugh  Walker,  m.d.,  m.b.,  cm. 
Large  8vo.     Qoth,  86  pages,  Illust net  $2.00 

GREEN,  ED  RIDGE-:    The  Hunterian  Lectures  on  Colour 
Vision  and  Colour  Blindness.      (See  Edridge-Green.) 

HARRIS:     Lectures  on  Medical  Electricity  to  Nurses.     An 
Illustrated  Manual  by  J.  Delpratt  Harris,  m.d.,  m.r.c.s. 
12mo.     Cloth,  88  pages,  Illust net  $1.00 

HELLMAN:    Amnesia  and  Analgesia  in  Parturition — ^Twi- 
light Sleep.     By  Alfred  M.  Hellman,  b.a.,  m.d.,  f.a.c.s. 
8vo.     Cloth,  with  charts,  200  pages net  $1.50 

HEW  ATT:     The    Examination    of    the    Urine,    and    Other 
Qinical  Side  Room  Methods.     By  Andrew  Fergus  Hewatt, 
I.I.B.,  CH.B.,  m.r,c.p.  Edin. 
16mo.     5th  Edition,  numerous  Illust net  $1.00 


HOEBER'S  MEDICAL  MONOGRAPHS  7 

HOFMANN-GARSON:  Remedial  Gymnastics  for  Heart 
Affections.  Used  at  Bad-Nauheim.  Being  a  Translation 
of  "Die  Gymnastik  der  Herzleidenden"  von  Dr.  Med.  Julius 
Hofmann  und  Dr.  Med.  Ludwig  Pohlman.  Berlin  and  Bad- 
Nauheim.  By  John  George  Garson,  m.d.  Edin.,  etc.  Physi- 
cian to  the  Sanatoria  and  Bad-Nauheim,  Eversley,  Hants. 
Large  8vo.     Cloth,   144  pages,  51   full-page  Illust net  $2.50 

HOWARD:    The   Therapeutic    Value    of   the    Potato.      By 
Heaton  C.  Howard,  l.r.c.p.  Lx)nd.,  m.r.c.s.  Eng. 
8vo.     Paper,  vi-|-31  pages,  Illust net  50c 

JANE  WAY,  BARRINGER  AND  FAILLA:  Radium  Ther- 
apy in  Cancer  at  the  Memorial  Hospital,  Report  of  1915- 
1916.  By  Henry  H.  Janeway,  m.d.,  with  the  Discussion  of  the 
Treatment  of  Cancer  of  the  Prostate  and  Bladder  by  Ben- 
jamin S.  Barringer,  m.d.,  and  an  Introduction  upon  the  Physics 
of  Radium  by  G.  Failla. 
8vo.    Cloth,  242  pages,  16  Illust net  $2.25 

JELLETT:  A  Short  Practice  of  Midwifery  for  Nurses. 
Embodying  the  treatment  adopted  in  the  Rotunda  Hospital, 
Dublin.  By  Henry  Jellett,  b.a.,  m.d.  (Dublin  University), 
F.R.C.P.I.,  Master  Rotunda  Hospital.  With  Six  Plates  and  169 
Illustrations  in  the  Text,  also  an  Appendix,  a  Glossary  of 
Medical  Terms,  and  the  Regulations  of  the  Central  Midwives 
Board. 
12mo.     Cloth,  xvi-f508  pages net  $2.50 

JONES:    Notes  on  Military  Orthopaedics.      By    Col.    Robert 
Jones,  c.b.,  Inspector  of  Military  Orthopaedics,  Army  Medical 
Service. 
8vo.     Cloth,  132  pages,  95  Illust net  $1.75 

KENWOOD:    Public  Health  Laboratory  Work.    By  Henry 
R.  Kenwood,  m.b.,  f.r.s.  Edin.,  p.p.h.,  f.c.s.,  Chadwick  Profes- 
sor of  Hygiene  and  Public  Health,  University  of  London.    6th 
Edition. 
8vo.    Cloth,  418  pages,  Illust net  $4.00 

KERLEY:     What  Every  Mother  Should  Know  About  Her 
Infants  and  Young  Children.     By  Charles  Gilmore  Kerley, 
M.D.    Professor  of  Diseases  of  Children,  N.  Y.  Polyclinic  Med- 
ical School  and  Hospital. 
8vo.    Paper,  107  pages net  35c 

KETTLE:     The  Pathology  of  Tumors.      By    E.    H.    Kettle, 
M.D.,  B.S.,  Assistant  Pathologist,  St.  Mary's  Hospital,  and  As- 
sistant Lecturer  on   Pathology,  St.  Mary's  Hospital. 
8vo.    Goth,  242  pages,  126  Illust net  $3.00 

LAMBERT:  A  Terminology  of  Disease.  To  facilitate  the 
Classification  of  Histories  in  Hospitals.  By  Adrian  V.  G. 
Lambert,  m.d.,  Associate  Professor  of  Surgery,  Columbia  Uni- 
versity ;  Director  Surgical  Research  Service,  Presbyterian  Hos- 
pital, N.  Y. 
12mo.    Cloth,  176  pages net  $225 


8  HOEBEKS  MEDICAL  MONOGRAPHS 

LEWERS:  A  Practical  Textbook  of  the  Diseases  of 
Women.  By  Arthur  H.  N.  Lewers,  m.d.  Lend.  Senior 
Obstetric  Physician,  London  Hospital. 

With  258  Illustrations,   13  Colored  Plates,  5  Plates  in  Black 
and  White.     7th  Edition. 
8vo.     Cloth,  xii+S40  pages net  $4.00 

LEWIS:  Clinical  Disorders  of  the  Heart  Beat.  A  Hand- 
book for  Practitioners  and  Students.  By  Thomas  Lewis, 
M.D.,  D.sc,  F.R.c.p.  Assistant  Physician  and  Lecturer  in  Car- 
diac Pathology,  University  College  Hospital  Medical  School. 
4th  Edition. 
8vo.     Cloth,  120  pages,  54  Illust net  $2.50 

LEWIS:     Lectures  on  the   Heart,     Comprising  the   Herter 
Lectures    (Baltimore),   a   Harvey   Lecture    (New   York),   and 
an  Address  to  the  Faculty  of  Aledicine  at  McGill  University 
(Montreal).    By  Thomas  Lewis. 
124  pages,  with  83  Illust net  $2.50 

LEWIS:  Clinical  Electrocardiography.  By  Thomas  Lewis. 
8vo.     Qoth,  2nd  Edition,   120  pages,   with  charts net  $2.50 

LEWIS:     The  Mechanism  of  the  Heart  Beat.    With  Special 
Reference  to  Its  Clinical  Pathology.     By  Thomas  Lewis. 
Large  8vo.    Qoth,  295  pages,  227  Illust.    New  Edition  in  prep- 
aration. 

LEWIS:    The  Soldier's  Heart  and  the  Effort  Syndrome.   By 
Thomas  Lewis. 
8vo.     Cloth,  156  pages net  $2.50 

McCLURE:     A  Handbook  of  Fevers.    By  J.  Campbell  Mc- 
Clure,  m.d.,  Glasgow.     Physician  to  Out-Patients,  The  French 
Hospital,  and  Physician  to  the  Margaret  Street  Hospital  for 
Consumption  and  Diseases  of  the  Chest,  London. 
8vo.     Cloth,  470  pages,  with  charts net  $3.50 

McCRUDDEN:      The    Chemistry,    Physiology    and    Pathol- 
ogy of  Uric  Acid,  and  the  Physiologically  Important  Purin 
Bodies.    With  a  Discussion  of  the  Metabolism  in  Gout.    By 
Francis  H.  McCrudden. 
12mo.     Paper,   318   pages net  $2,00 

McKISACK:     Systematic  Case  Taking.     A  Practical  Guide 
to   the    Examination   and    Recording   of    Medical    Cases.      By 
Henry  Lawrence  McKisack,  m.d.,  m.r.c.p.  Lond. 
12mo.     Cloth,  166  pages   net  $1.75 

MACKENZIE:    Symptoms   and   Their  Interpretation,      By 

James  Mackenzie,  m.d.,  ll.d.  Aber.  and  Edin.    Third  Edition. 

8vo.     Cloth,   Illust.   xxii+318  pages net  $4.00 

MACKENZIE:    The  Action  of  Muscles.  By  Willlam  Colin 
Mackenzie,  m.d.,  f.r.c.s.,  f.r.s.  (Edin.) 
8vo.    Cloth,  267  pages,  99  Illust.    New  Edition  in  preparation. 


HOEBER'S  MEDICAL  MOHOGRAPHS  9 

MACMICHAEL:  The  Gold-Headed  Cane.  By  William 
Macmichael.  Reprinted  from  the  2nd  Edition.  With  a  Pref- 
ace by  Sir  William  Osier  and  an  Introduction  by  Dr.  Fran- 
cis R.  Packard.  Printed  from  large  Scotch  type  on  a  special 
heavy-weight  paper,  5J4  by  7^  inches,  bound  in  blue  Italian 
handmade  paper,  with  parchment  back,  gilt  top,  square  back, 
and  gold  stamping  on  back  and  side net  $3.00 

MAGILL:    Notes  on  Galvanism  and  Faradism.    By  E.  M. 
Magill,  M.B.,  B.S.  Lond.,  r.c.s.i.     (Hons.)  2nd  Edition. 
12mo.     Cloth,  xvi+224  pages,  67  Illust net  $2.00 

MANUAL:     See  United  States  Army  X-Ray  Manual. 

MARTINDALE     and     WESTCOTT:     ."Salvarsan"     "606" 
Dioxy-Diatnino-Arsenobenzol),    Its    Chemistry,    Pharmacy 
and  Therapeutics.     By  W.  Harrison  Martindale,  ph.d.  Mar- 
burg, F.C.S.,  and  W.  Wynn  Wescott,  m.b. 
8vo.     Cloth,  xvi+76  pages net  $1.50 

MINETT:    Diagnosis  of  Bacteria  and  Blood  Parasites.    By 

E.  P.   MiNETT,    M.D.,   D.P.H.,   D.T.M.   and    H.,    M.R.C.S.,   L.R.C.P. 

12mo.     Cloth,  viii+80  pages tiet  $1.00 

MITCHELL:  Memoranda  on  Army  General  Hospital  Ad- 
ministration. By  Various  Authors.  Edited  by  Peter  Mit- 
chell, M.D.  Aberd.,  Lieut.-Colonel  R.A.M.C.  (T.  F.),  Officer 
Commanding  No.  43  General  Hospital. 

8vo.     Qoth,  v+109  pages,  Illust.  with  vii  pi net  $2.25 

MOTT:     Nature  and  Nurture  in  Mental  Development.     By 

F.  W.  MoTT,   M.D.,  F.R.S.,  F.R.C.P.     Pathologist  to  the  London 
County  Asylums. 

12mo.     Cloth,   151  pages,  with  diagrams net  $1.75 

MUNSON:  Hygiene  of  Communicable  Diseases.  By  Lieut. 
Francis  M.  Munson,  U.  S.  N.,  Retired.  Lecturer  on  Hygiene 
and  Instructor  in  Military  Surgery,  School  of  Medicine, 
Georgetown  University;  Late  Brigade  Surgeon,  2d  Provisional 
Brigade,  U.  S.  Marines.  Published  with  the  approval  of  the 
Bureau  of  Medicine  and  Surgery  of  the  Navy  Department,  and 
by  permission  of  the  Secretary  of  the  Navy. 

12mo.     Flexible  cloth,  800  pages,  Illust In  Press 

MURRELL:  What  to  Do  in  Cases  of  Poisoning.  By  Wil- 
liam Murrell,  M.D.,  F.R.C.P.  Senior  Physician  to  the  West- 
minster Hospital.     11th  Edition. 

16mo.     Cloth,  283  pages ttet  $1.00 

NEUROLOGICAL  BULLETIN.  Qinical  Studies  of  Nerv- 
ous and  Mental  Diseases  in  the  Neurological  Department  of 
Columbia  University.  Edited  by  Frederick  Tilney,  m.d.,  ph.d.  ; 
Associate  Editor,  Louis  Casamajor,  m.d.;  Editorial  Board;  S. 
P.  Goodhart,  m.d.,  F.  M.  Hallock,  m.d.,  Randal  Hoyt,  m.d.,  C. 
A.  McKendree,  m.d.,  Michael  Osnato,  m.d.,  Oliver  S.  Strong, 
PH.D.,  I.  S.  Wechsler,  m.d.  Published  monthly. 
Vol.  I,  1918,  $3.00;  Vol.  II,  1919.    Yearly  subscription  net  $5.00 


lo  HOEBER'S  MEDICAL  MONOGRAPHS 

OLIVER:  Lead  Poisoning:  From  the  Industrial,  Medical 
and  Social  Point  of  View.  Lectures  Delivered  at  Royal  In- 
stitute of  Public  Health.    By  Sir  Thomas  Oliver,  m.a.,  m.d., 

F.R.C.P. 

12mo.     Cloth,  294  pages net  $2.25 

OLIVER:     Studies    in    Blood    Pressure,    Physiological   and 
Clinical.     By  George  Oliver,  m.d.,  Lond.,  f.r.c.p.     Edited  by 
W.  A.  Halliburton,  m.d.,  f.r.s. 
8vo.     Cloth,  xxiv,  240  pages,  Illust net  $3.00 

OSLER:  Two  Essays.  By  Sir  William  Osler,  m.d.,  Regius 
Professor  of  Medicine  at  Oxford. 

Vol  1.     A  Way  of  Life.     An  Address  to  Yale  Students, 
Sunday  Evening,  April  20th,  1913. 

16mo.     Cloth,  61   pages net  75c 

Vol.  2.    Man's  Redemption  of  Man.    A  Lay  Sermon,  Mc- 
Ewan  Hall,  Edinburgh,  Sunday,  July  2d,  1910. 
16mo.     Cloth,  63  pages net  75c 

OSLER  ANNIVERSARY  VOLUME:  See  Contributions 
to  Medical  and  Biological  Research. 

OSNATO:  Aphasia  and  Associated  Speech  Problems.  By 
Michael  Osnato,  m.d.,  Associate  in  Neurology,  Columbia 
University ;  Consulting  Physician  Manhattan  State  Hospital 
and  Central  Islip  State  Hospital ;  Assistant  Chief  of  Clinic, 
Vanderbilt  Clinic,  Department  of  Neurology. 
12mo.     Cloth,  200  pages,  Illust net  $2.50 

OTT:    Fever,  Its  Thermotaxis  and  Metabolism.       By   Isaac 
Ott,  a.m.,  m.b. 
12mo.    Cloth,  168  pages,  Illust net  $1.50 

OWEN:  The  Legislative  and  Administrative  History  of 
the  Medical  Department  of  the  United  States  Army  Dur- 
ing the  Revolutionary  Period  (1776-85).  By  Col.  William 
O.  Owen,  U.  S.  A.,  Curator  Army  Medical  Museum,  Wash- 
ington, D.  C. 
12mo.     Cloth,  226  pages,  Illust 

PAGET:     For  and  Against  Experiments  on  Animals.     Evi- 
dence   before    the    Royal     Commission    of    Vivisection.      By 
Stephen  Paget,  f.r.c.s.     With  an  Introduction  by  The  Right 
Hon.  The  Earl  of  Cromer. 
8vo.    Cloth,  xii+344  pages,  Illust net  $1.75 

PATON:    Education  in  War  and  Peace.  By  Stewart  Paton, 
M.D.,  Lecturer  in  Neurobiology,  Princeton  University,  Lecturer 
Psychiatry,  Columbia  University. 
12mo.     Boards,    125   pages In  Press 

PEGLER:  Map  Scheme  of  the  Sensory  Distribution  of 
the  Fifth  Nerve  (Trigeminus)  with  Its  Ganglia  and  Con- 
nections. By  L.  Hemington  Pegler,  m.d.,  m.r.c.s.  Senior 
Surgeon,  Metropolitan  Ear,  Nose  and  Throat  Hospital,  etc. 
Folded  in  Cloth  Binder net  $10.00 


HOEBEKS  MEDICAL  MONOGRAPHS  n 

PICKERILL:     The  Prevention  of  Dental  Caries  and  Oral 
Sepsis.    By  H.  P.  Pickeriix,  m.d.,  ch.b.m.d.s.,  l.d.s.,  Professor 
of  Dentistry  and  Director  of  the  Dental  School  in  the  Univer- 
sity of  Otago.     Second  Edition,  1919. 
8vo.     Cloth,  xvi+374  pages,  Illust net  $5.00 

RAWLING:    Landmarks  and  Surface  Markings  of  the  Hu- 
man Body.     By  L.   Bathe  Rawling,   m.b.,  b.c,   f.r.c.s.     5th 
Edition. 
8vo.     Cloth,  31  pi.,  xii+96  pages  of  text net  $2.50 

RITCHIE:  Auricular  Flutter.  By  William  Thomas  Ritchie, 
M.D.,  F.R.C.P.E.,  F.R.s.E.  Physician  to  the  Royal  Infirmary. 
Large  8vo.     Qoth,  156  pages,  21  pi.  107  Illust net  $3.50 

ROCKWELL:     Rambling  Recollections.    An  autobiography 
by  A.  D.  Rockwell,  m.d. 
Svo.     Cloth,  332  pages,  7  Illust net  $4.00 

RUTHERFORD:    The  Ileo-Caecal  Valve.      By  A.   H.   Ru- 
therford,  m.d.   Edin. 
Svo.    Cloth,  63  pages  of  text,  23  full  page  pi.  3  colored  net  $2.50 

SAALFELD:  Lectures  on  Cosmetic  Treatment.  A  Manual 
for  Practitioners.  By  Dr.  Edmund  Saalfeld  of  Berlin. 
Translated  by  J.  F.  Dally,  m.a.,  m.d.,  b.c.  Cantab.,  m.r.c.p. 
Lond.     With  an  Introduction  and  Notes  by  P.   S.  Abraham, 

M.A.,    M.D.,    B.SC,    F.R.C.S.I. 

12mo.     Cloth,  xii+186  pages,  Illust net  $1.75 

SCHOOL  OF  SALERNUM,  THE.  Including  Regimen  Sani- 
tatis  Salemitatum,  and  Sir  John  Harrington's  English  Ver- 
sion, with  an  Introduction  by  Francis  R.  Packard,  m.d.,  and 
a  Note  on  the  Prehistory  of  the  Regimen  Sanitatis  by  Field- 
ing H.  Garrison,  m.d. 

IllusL    In  Press. 

SCOTT:    Modem   Medicine  and   Some   Modem   Remedies. 
By   Thomas   Bodley   Scott,   with   a    Preface   by    Sir   Lauder 
Brunton.    2nd  Edition. 
12mo.     Cloth,  xv-l-198  pages net  $2.00 

SCOTT:    The   Road   to   a   Healthy   Old   Age.     Essays   by 
Thomas  Bodley  Scott,  m.d. 
12mo.    Qoth,  104  pages net  $1.00 

SENATOR  and  KAMINER:  Marriage  and  Disease.  Being 
an  Abridged  Edition  of  "Health  and  Disease  in  Relation  to 
Marriage  and  the  Married  State."  By  Prof.  H.  Senator  and 
Dr.   S.   Kaminer.     Trans,   from  the   German  by  J.   Dulberg, 

M.D. 

Svo.     Qoth,  452  pages net  $2.50 

SLOAN:    Electro-Therapy  in  Gr3mecology.             By  Samuel 
Sloan,  m.d.,  f.r.f.p.s.g..  Consulting  Physician  to  the  Glasgow 
Royal  Maternity  and  Women's  Hospital,  etc. 
Svo.     Qoth,  320  pages,  39  Illust net  $4.00 


12  HOEBER'S  MEDICAL  MONOGRAPHS 

SMITH:  Studies  in  the  Anatomy  and  Sxorgery  af  the  Nose 
and  Ear.  By  Adam  E.  Smith,  m.d.,  Past  Chief  Medical  and 
Sanitary  Officer,  Nile  Reservoir  Works,  Assuan,  Egypt;  Past 
Instructor  in  Operative  Surgery,  College  of  Fliysicians  and 
Surgeons,  and  Past  Attending  Surgeon,  German  Hospital, 
O.P.D.,  New  York. 
Large  8vo.    Cloth,  168  pages,  45  pi tvet  $4.00 

SMITH :    Some  Common  Remedies,  and  Their  Use  in  Prac- 
tice.   By  Eustace  Smith,  m.d. 
12mo.     Cloth,   viii+112  pages net  $125 

SQUIER   and   BUGBEE:    Manual   of    Cystoscopy.     By   J. 

Bentley  Squier,  m.d.     Professor  of  Genito-Urinary  Surgery, 
New  York  Post-Graduate  Medical  School  and  Hospital,  and 
Henry  G.  Bugbee,  m.d.    Adopted  by  the  U.  S.  Army. 
8vo.     Flex.  Leather,  xiv-j-117  pages,  26  colored  pi... net  $3.00 

STARK:    The  Growth  and  Development  of  the  Baby.     A 

tabular  chart,  giving  the  result  of  personal  observation,  veri- 
fied by  authoritative  data,  as  to  development,  weight,  height, 
etc.,  during  the  first  seven  years.  By  Morris  Stark,  m.a.,  b.s., 
M.D.  Instructor  of  Pediatrics,  N.  Y.  Post-Graduate  Med.  Sch. 
Heavy  Paper,  20  by  25  inches net  SOc 

STEPHENSON:    Eye-Strain    in    Every-day    Practice.      By 

Sidney  Stephenson,  m.b.,  cm.  Edin.,  d.o.  Oxon.,  f.r.c.s.  Edin. 

Editor  of  the  Ophthalmoscope. 

8vo.    Qoth,  x+139  pages net  $1.75 

STEWART:  Physical  Reconstruction  and  Orthopedics.  By 
Harry  Eaton  Stewart,  m.d..  Captain  Medical  Corps.,  U.  S.  A., 
Division  of  Orthopedics ;  Instructor  in  Medical  and  Ortho- 
pedic Gymnastics  and  Massage,  New  Haven  Normal  School 
of  Gymnastics ;  Attending  Surgeon,  New  Haven  Orthopedic 
Dispensary.  Authorized  for  Publication  by  the  Surgeon-Gen- 
eral, U.  S.  A. 
8vo.     Cloth,  250  pages,  with  67  original  Illust $3.75 

SWIETOCHOWSKI:    Mechano-Therapeutics     in     General 
Practice.     By  G.  de  Swietochowski,  m.d.,  m.r.c.s.    Fellow  of 
the  Royal  Society  of  Medicine;   Clinical  Assistant,  Electrical 
and  Massage  Department,  King's  College  Hosp. 
12mo.     Cloth,  xiv-1-141  pages,  31  Illust net  $1.75 

TOUSEY:  Roentgenographic  Diagnosis  of  Dental  Infec- 
tion in  Systemic  Diseases.  By  Sinclair  Tousey,  a.  m.,  m.d. 
8vo.     Cloth,  75  pages  and  64  Illust net  $1.50 

Transactions  of  the  Twenty-Third  Annual  Meeting  of  the 
American  Laryngological,  Rhinological  and  Otological  So- 
ciety, 1917.       Paul  B.  Hoeber,  distributor. 

1918.  8vo.     Qoth,  vii-f363  pages,  with  Illust net  $3.50 

1919.  8vo.     Qoth,  vii+436  pages,  46  Illust net  ^4.00 


HOEBER'S  MEDICAL  MOKOGRAPHS  13 

TRUESDELL:  Birth  Fractures  and  Epiphyseal  Disloca- 
tions. By  Edward  D.  Truesdell,  m.d.,  Assistant  Attending 
Surgeon  and  Roentgenologist,  Lying-in  Hospital,  Associate 
Surgeon,  St.  Mary's  Free  Hospital  for  Children,  New  York. 
Large  8vo.     Qoth,   135  pages,   151   Illust net  $4.00 

TURNER  and  PORTER:  The  Skiagraphy  of  the  Accessory 
Nasal  Sinuses.  By  A.  Logan  Turner,  m.d.,  f.r.c.s.e.,  f.r.s.e. 
Surgeon  to  the  Ear  and  Throat  Department,  the  Royal  In- 
firmary, Edinburgh,  and  W.  G.  Porter,  m.b.,  b.sc.,  f.r.c.s.e. 
Surgeon  to  Eye  and  Throat  Infirmary,  Edinburgh. 
Quarto,  Cloth,  45  pages  of  text,  39  pi net  $6.00 

UNITED    STATES   ARMY   X-RAY    MANUAL:    Author- 
ized by  the  Surgeon  General  of  the  Army.     Prepared  under 
the  Direction  of  the  Division  of  Roentgenology. 
12mo.    Flexible  Leatherette,  506  pages,  219  Illust net  $4.50 

von    RUCK    and    von    RUCK:      Studies    in    Immunization 
against  Tuberculosis.    By  Karl  von  Ruck,  m.d.,  and  Silvio 
VON  Ruck,  m.d. 
8vo.     Qoth,  xvi+439  pages net  $4.00 

WANKLYN:  How  to  Diagnose  Smallpox.  A  Guide  for 
General  Practitioners,  Post-Graduate  Students,  and  Others. 
By  W.  McC.  Wanklyn,  b.a.  Cantab.,  M.R.C.S.,  l.r.c.p.,  d.p.h... 
8vo.     Qoth,  102  pages,  Illust net  $1.50 

WATSON:    Gonorrhoea  and  Its  Complications  in  the  Male 
and  Female.     By  David  Watson,   m.b.,  cm..   Surgeon,   Glas- 
gow  Lock   Hospital    Dispensary,    Surgeon    for   Venereal   Dis- 
eases,  Glasgow  Royal   Infirmary,   etc.,  etc. 
Svo.    Goth,  375  pages,  72  Illust.,  12  pi.  some  colored.. net  $4.00 

WEBER:    Aspects    of    Death    and    Correlated    Aspects    of 
Life  in  Art,  Epigram  and  Poetry.      By    Frederick    Parkes 
Weber,   m.a.,   m.d.,  f.r.c.p.,  f.s.a.     Third   Edition. 
Svo.    Cloth,  784  pages,  144  Illust net  $7.50 

WHALE:  Injuries  to  the  Head  and  Neck.  By  H.  Lawson 
Whale,  m.d.  Camb.,  f.r.c.s.  Eng.,  Capt.  R.  A.  M.  C.  (T.  F.), 
formerly  Capt.  I.  M.  S.  (Retired);  The  Queen's  Hospital, 
Sidcup ;  No.  83  General  Hospital ;  Surgical  Specialist  to  No. 
53  General  Hospital,  B.  E.  F. ;  Surgeon  for  the  E^r,  Throat, 
and  Nose  to  the  London  Temperance  Hospital ;  and  to  the 
Hampstead  General  Hospital.  With  preface  by  Colonel  Fred- 
erick   F.    BuRGHARD,   C.B.,    M.D.,    M.S.,    F.R.C.S. 

Svo.    Cloth,  ix-l-322  pages,  105  Illust net  $5.00 

WHITE:    The  Pathology  of  Growth,  Tumours.  By  Charles 
Powell  White,  m.c,  f.r.c.s.    Director,  Pilkington  Cancer  Re- 
search  Fund,   Pathologist  Christie  Hospital,   Special  Lecturer 
in  Pathology,  University  of  Manchester. 
Svo.     Qoth,  xvi-|-235  pages,  Illust net  $3.50 


14  HOEBER'S  MEDICAL  MOHOCRAPHS 

WHITE:    Chronic  Traumatic  Osteomyelitis.   By  J.  Renfrew 
White,  m.b.,  f.r.c.s.,  Formerly  Resident  Surgeon  Officer,  Royal 
National   Orthopedic   Hospital,    London ;    Orthopedic    Surgeon 
New  Zealand   Forces. 
8vo.     Cloth,  160  pages,  Illust net  $3.00 

WHITE:  Occupational  Affections  of  the  Skin.  A  brief  ac- 
count of  the  trade  Processes  and  Agents  which  give  rise  to 
them.  By  P.  Prosser  White,  m.d.,  Ed.,  m.r.c.s.  Lond.  Life 
Vice-President,  Senior  Physician  and  Dermatologist,  Royal 
Albert  Edward  Infirmary. 
8vo.     Cloth,  165  pages net  $2.50 

WHITE:    Thoughts    of   a    Psychiatrist    on    the    War   and 
After.    By  William  A.  White,  m.d..  Superintendent  St.  Eliza- 
beth's  Flospital,   Washington,   D.    C. ;    Professor   of    Nervous 
and  Mental  Diseases,  Georgetown  University. 
12mo.     Boards,   144  pages net  $1.75 

WICKHAM  and  DEGRAIS:  Radium.  As  Employed  in  the 
Treatment  of  Cancer,  Angiomata,  Keloids,  Local  Tuberculosis 
and  Other  Affections.  By  Louis  Wickham,  m.v.o.,  Medecin 
de  St.  Lazare;  Ex-Chef  de  Clinique  a  L'Hopital  St.  Louis,  and 
Paul  Degrais,  Ex-Chef  de  Laboratoire  a  L'Hopital  St.  Louis. 
8vo.     Cloth,    viii+111  pages,  53  Illust net  $1.50 

WRENCH:    The  Healthy  Marriage.    A  Medical  and  Psycho- 
logical Guide  for  Wives.     By  G.  T.  Wrench,  m.d.,  b.s.  Lond., 
Past  Assistant  Master  of  the  Rotunda  Hospital,  Dublin.    2nd 
Edition. 
8vo.     Qoth,   viii+300   pages net  $1.75 

WRIGHT:    The   Unexpurgated   Case  against  Woman   Suf- 
frage.   By  Sm  Almroth  E.  Wright,  m.d.,  f.r.s. 
8vo.    Cloth,  xii+188  pages net  $1.25 

WRIGHT:  On  Pharmaco-Therapy  and  Preventive  Inocu- 
lation. Applied  to  Pneumonia  in  the  African  Native,  with 
a  Discourse  on  the  Logical  Methods  Which  Ought  to  Be  Em- 
ployed in  the  Evaluation  of  Therapeutic  Agents.  By  Sir 
Almroth  E.  Wright,  m.d.,  f.r.s. 
8vo.     Cloth,    124  pages net   $2.00 

X-RAY  MANUAL:     See  United  States  Army  X-Ray  Manual. 

YOUNG:  The  Mentally  Defective  Child.  By  Meredith 
Young,  m.d.,  d.p.h.,  d.s.sc.  Chief  School  Medical  Officer, 
Cheshire  Education  Committee;  Lecturer  in  School  Hygiene, 
Victoria  University  of  Manchester ;  Certifying  Medical  Offi- 
cer to  Local  Authority  (Mental  Deficiency  Act),  Co.  Cheshire. 
12mo.     Cloth,  xi+140  pages,   Illust net  $1.75 

Complete  catalogue  and  descriptive  circulars  sent  on  request. 


4473     9 


I 


UNIVERSITY  OF  CALIFORNIA  LIBRARY 

Los  Angeles 

This  book  is  DUE  on  the  last  date  stamped  below. 


DEC  1  *  I960 
OEC  2  7  196-J 

DtSCK 


JUN    9  1981 


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